Failure to Document and Implement Advance Directive Consistently
Penalty
Summary
The facility failed to properly document and implement an appropriate advance directive for one resident. The resident, who was severely cognitively impaired and had diagnoses including hypertension, diabetes, and non-Alzheimer's dementia, had both a signed Out of Hospital Do Not Resuscitate (DNR) Declaration and Order, as well as a Physician Orders for Scope of Treatment (POST) form indicating DNR status. Despite these documents, the resident's clinical record contained a current, open-ended physician's order for Cardiopulmonary Resuscitation (CPR). Interviews with staff revealed that the process for completing and transcribing POST forms and DNR orders involved both nursing and social services staff, with an expectation that the POST form and physician's orders would match. The Director of Nursing confirmed that if a resident had an Out of Hospital DNR, there should not be a physician's order for CPR. The facility's policy required adherence to residents' rights to formulate advance directives and procedures to communicate code status, but this was not followed in this instance.