Failure to Maintain Accurate Advance Directive Documentation
Penalty
Summary
The facility failed to maintain consistent and accurate advance directive information for one resident. Upon admission, the resident was alert and verbal, and the electronic medical record contained an order for full code status, created by the Director of Clinical Services. The resident's care plan also indicated full code status, with an intervention to honor resident choice. However, the paper medical record included a Medical Orders for Scope of Treatment (MOST) form and a Golden Rod DNR form, both indicating the resident's choice for do not attempt resuscitation (DNR), which were signed after admission. Interviews with the nurse practitioner and the Director of Clinical Services revealed confusion regarding the resident's advance directive wishes at the time of admission. As a result, the resident was initially assigned full code status in the electronic record until further discussion could clarify her wishes. Despite the completion of the MOST and Golden Rod DNR forms, the electronic medical record and care plan were not updated to reflect the resident's DNR status. The Director of Clinical Services acknowledged that both the electronic and paper records should have matched and that the care plan should have been updated to reflect the resident's current wishes.