Failure to Document and Care Plan Advance Directive and Code Status
Penalty
Summary
The facility failed to follow its own policy and procedure regarding advance directives for one resident. Specifically, the resident's face sheet had a blank section for advance directives, and the order summary report showed no physician order for the resident's code status. Additionally, the resident's comprehensive care plan did not address advance directives or code status. The resident was cognitively intact, as indicated by a BIMS score of 14. According to the Social Service Director, code status preferences are to be obtained upon admission, reviewed quarterly, and documented in the physician orders, face sheet, and care plan, with the POLST form uploaded to the electronic medical record. The facility's guidelines require that the resident's wishes, physician orders, and care plan all match regarding advance directives, but this was not done for the resident in question.