Failure to Accurately Document and Process Advance Directives
Penalty
Summary
The facility failed to accurately and completely document and process advance directives for one resident. Upon review, the resident's care plan did not include any focus, goals, or interventions related to the resident's wishes for cardiopulmonary resuscitation (CPR), despite the presence of significant cardiac diagnoses. The facility's policy required that advance directive forms be reviewed with the resident upon admission and forwarded to the physician for signature, but this process was not followed. The resident's physician orders and initial history indicated a full code status, but the actual advance directive form was not present in the facility's CPR Binder, which staff rely on during emergencies. Interviews revealed that the resident was not given the opportunity to review advance directive paperwork upon admission and later expressed a desire to be DNR (do not resuscitate), which was not reflected in the documentation available to staff. The social worker acknowledged that the advance directive form had not been provided to the physician for signature, meaning the resident's wishes would not be honored in the event of a cardiac or respiratory arrest. This series of omissions resulted in the potential for the resident's preferences regarding life-sustaining treatment to not be followed.