Inconsistent Documentation of Advance Directives and Code Status Orders
Penalty
Summary
The facility failed to ensure that residents' advance directives, specifically their POLST forms and physician orders, were consistent and accurately reflected their treatment wishes in the event of a medical emergency. In three cases, residents had signed POLST forms indicating Do Not Attempt Resuscitation (DNR), but their physician orders and care plans either indicated full code status or did not have corresponding orders, resulting in conflicting information about their code status. For example, one resident with multiple diagnoses, including end-stage renal disease and a kidney transplant, was cognitively intact and had a signed POLST indicating DNR, but the active physician order and care plan listed the resident as full code, instructing staff to attempt resuscitation. Staff interviews revealed confusion and reliance on different sources within the electronic medical record (EMR) to determine code status. LPNs reported checking the EMR dashboard and active orders, but these did not always match the signed POLST forms. In one instance, a nurse acknowledged the conflicting information between the dashboard, active order, and POLST, and another nurse was unable to locate the POLST in the EMR due to unfamiliarity with the system. The facility's process involved social services uploading POLST forms and updating care plans, but only nursing staff entered orders, leading to gaps in communication and documentation. The facility's policy required that advance directives be reviewed upon admission, communicated to staff, and periodically reviewed during care planning. However, in these cases, the policy was not followed, resulting in discrepancies between residents' documented wishes and the orders available to staff during emergencies. This failure to ensure consistency and proper communication of advance directives affected multiple residents and was confirmed through record review and staff interviews.