Failure to Communicate Resident Advance Directive to Care Staff
Penalty
Summary
The facility failed to communicate a resident's advance directive choice to the staff responsible for their care. A review of the clinical record for a resident with diagnoses including cerebral infarction, left side hemiplegia, and schizophrenia revealed that documentation of the Indiana Physician Orders for Scope of Treatment (POST) form was missing from both the electronic health record (EHR) and the binder at the nurse's station. The Director of Nursing (DNS) confirmed that the POST form, which indicated the resident requested CPR and full medical attention, was not available in the expected locations and was only later found in a scanned pile not accessible at the nurse's station. Facility policy requires that advance directives be copied, placed on the chart, and communicated to staff upon admission, but this was not done for the resident in question.