Failure to Accurately Document and Update Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately reflected in both the physician orders and the care plan. The resident, who had diagnoses including acute kidney failure, hypertension, osteoarthritis, and muscle wasting with atrophy, was admitted with impaired cognition. The care plan dated 12/10/24 indicated the resident was a full code, while a DNR Comfort Care form signed by the primary care physician on 12/26/24 indicated the resident was to be DNR comfort care. However, the physician order in the electronic medical record, dated 12/27/24, still listed the resident as DNR comfort care-arrest, which did not match the most recent DNR Comfort Care form. Interviews with both an LPN/MDS nurse and the DON confirmed that the care plan and physician orders were inaccurate and did not reflect the resident's current advance directive status. The facility's policy required that any changes to advance directives be communicated to the care plan team and documented appropriately, but this process was not followed, resulting in discrepancies between the resident's documented wishes and the orders in the medical record and care plan.