Failure to Honor Resident's Advance Directive Preferences
Penalty
Summary
The facility failed to accurately identify and honor a resident's advance directive regarding life-sustaining treatment. A review of the clinical record for a resident with osteoarthritis and atrial fibrillation showed that the resident had a completed and signed POLST form indicating a Do Not Resuscitate (DNR) status, with a goal of allowing a natural death. However, the resident's current physician orders in the electronic health record incorrectly listed the code status as Full Code, which would require CPR in the event of cardiopulmonary arrest. There was no documentation in the clinical notes or care conference records to indicate that the resident had revised the advance directive or changed the preference documented on the POLST. An interview with the Director of Nursing confirmed that physician orders are required to align with the most current, signed POLST, and acknowledged the discrepancy between the resident's documented wishes and the physician orders. This failure resulted in the resident's treatment preferences not being properly reflected in the medical record.