Failure to Update Advance Directive in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directive, specifically an Out-of-Hospital Do Not Resuscitate (OOHDNR) order, was properly updated in the medical record after it was signed by the physician. The resident, a female with severe cognitive impairment and multiple diagnoses including cerebral palsy, epilepsy, hypertension, and gastrostomy status, had a face sheet indicating a full code status, despite her guardian having requested and signed a DNR that was later signed by the attending physician. The care plan noted the need to complete and update the advance directives document, but the order summary continued to reflect a full code status. Interviews with facility staff revealed a lack of clarity and follow-through regarding responsibility for updating the resident's code status. The Social Services Designee stated that after receiving a signed OOHDNR, she provided a copy to the nurses and uploaded it to the electronic medical record (EMR), but expected the nurses to update the code status. The ADON and LVN both indicated that in an emergency, they would rely on the code status displayed in the EMR or on the resident's door, and not review uploaded documents. The DON and Administrator both confirmed that the code status should have been updated immediately upon receipt of the signed OOHDNR, and acknowledged that failure to do so could result in actions contrary to the resident's wishes. Facility policy required that advance directives be honored and that copies be maintained in a readily retrievable section of the resident's medical record. The policy also specified that the DNS or designee notify the attending physician of any changes so that appropriate orders could be documented. Despite these requirements, the resident's code status remained listed as full code after the OOHDNR was signed and uploaded, resulting in a failure to honor the resident's advance directive as documented.