Failure to Maintain Accurate Advance Directives in Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date advance directives in the medical records for two residents. For one resident, the care plan indicated a full code status, while a physician's order and a signed DNR form in the advance directive binder reflected a Do Not Resuscitate (DNR) status. Staff interviews revealed confusion regarding the resident's current code status, with the nurse relying on the care plan, which was outdated, and the Social Services Director unaware of the change due to being on leave. The responsibility for updating the care plan was unclear among staff, with the Social Worker, MDS Coordinator, and Unit Manager each providing different accounts of who should update the documentation. For another resident, the care plan also indicated a full code status, despite a recent physician's order and signed DNR form indicating a change to DNR. The Social Services Director acknowledged that the code status must have changed after a hospital stay and was not updated in the care plan. The Social Services Assistant, who attended the care plan meeting where the change was discussed, did not update the care plan and was unsure of her responsibilities, as she was still in training. The Administrator confirmed that both Social Workers and the MDS Coordinator were responsible for updating care plans to reflect changes in advance directives.