Failure to Ensure Accurate and Accessible Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that advance directive wishes and code status information were accurately documented and readily accessible for two residents. For one resident with diagnoses including heart failure, bipolar disorder, and depression, and who was cognitively intact, the care plan indicated a Full Code status. However, the resident's electronic health record (EHR) face sheet did not include code status information, and the Iowa Physician Orders for Scope of Treatment (IPOST) was not present in the nurse's station binder or the EHR. The Director of Nursing (DON) confirmed the absence of this documentation. For another resident with non-Alzheimer's dementia, seizure disorder, and mild intellectual disabilities, and who had severely impaired cognition, the care plan indicated a Do Not Resuscitate (DNR) status. While staff stated that code status information was available in a binder, the IPOST for this resident was not initially found under the appropriate tab. It was located under a different tab after a delay. The DON acknowledged that code statuses should be up to date and accessible in the binder, and facility policy required CPR to be carried out in accordance with residents' advance directives or, in their absence, to assume Full Code status.