Failure to Maintain Consistent Advance Directive Documentation
Penalty
Summary
The facility failed to maintain accuracy and consistency of a resident's advance directive throughout the medical record. One resident was admitted with an advance directive indicating full code status in the care plan, with interventions including the administration of CPR. However, a physician's order and the advance directive binder at the nurses' station both indicated the resident was designated as Do Not Resuscitate (DNR). This inconsistency was present across different documentation sources within the facility. During interviews, nursing staff and the MDS Coordinator acknowledged the discrepancy, noting that the care plan had not been updated to reflect the current DNR status. The MDS Coordinator, responsible for updating the care plan, stated that routine audits are conducted but was unable to explain why this resident's care plan was missed, attributing it to an oversight. The Director of Nursing and the Administrator both confirmed their expectation that the care plan should be updated in a timely manner to match any changes in code status.