Failure to Document and Honor Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that four residents had their rights related to treatment choices, advance directives, and code status properly documented and protected. For one resident, the signed Advance Directive was not found in the chart, despite documentation in the EHR that the resident had been given copies and had signed the forms. The Social Services staff and Unit Clerk were unable to locate the paperwork in either the current or archived charts, and the resident herself was unsure if she had an Advance Directive in place. The Director of Nursing confirmed that the documentation should have been present in the chart as per facility policy. Another resident expressed a desire to formulate an Advance Directive, and the Social Services note indicated that the conservator was contacted. However, there was no follow-up documentation or acknowledgement form found in the chart, and the resident did not recall being offered the Advance Directive. The Social Services staff and Director of Medical Records both verified that the documentation was missing and should have been included in the resident's record. A third resident's chart did not contain documentation regarding an Advance Directive discussion, and the resident had refused the initial assessment due to anxiety. The Social Services staff acknowledged that no follow-up or documentation was completed. For a fourth resident, neither the electronic health record nor the physical chart contained documentation of the resident's code status, and staff relied on the color of the chart label to determine code status in the absence of formal documentation. The Director of Nursing and other staff confirmed that the code status should have been clearly documented in both the EHR and physical chart.