Failure to Document and Implement Resident's Advance Directive and DNR Status
Penalty
Summary
The facility failed to honor a resident's right to have their advance directive wishes accurately documented and implemented. Upon admission, the resident expressed a desire to be a Do Not Resuscitate (DNR) and signed an Advance Directive form. Both the resident and staff confirmed these wishes. However, the resident's physician orders did not include any documentation of the Advance Directive, and the care plan was not updated to reflect the resident's DNR status. The facility's policy requires that a written physician's order be included in response to advance directives and that this information be incorporated into the care plan. Despite the resident's wishes and the facility's policy, there was no POLST (Physician Orders for Life-Sustaining Treatment) form or Advance Directive present in the resident's electronic health record or in the code status binder at the nurse's station. Staff interviews confirmed that the POLST form had been sent to the physician for signature but had not been returned or uploaded into the system. As a result, the resident would be considered a full code and would receive CPR, contrary to their stated wishes.