Inconsistent Documentation of Advance Directives for Emergency Treatment
Penalty
Summary
The facility failed to ensure that a resident's advance directives for emergency treatment were consistently and accurately reflected across all areas of the medical record. Specifically, for one resident who was cognitively intact and had diagnoses including hyperlipidemia and schizophrenia, there was a discrepancy between the documented code status in different parts of the medical record. The resident's signed code status form, which was also signed by a family member and physician, indicated a Do Not Resuscitate (DNR) order. However, the physician orders in the electronic medical record (EMR) listed the resident as FULL CODE. Interviews with facility staff, including a trained medical assistant, a registered nurse, and the director of nursing (DON), revealed that staff relied on various sources such as the hard chart, face sheet, and medication administration record (MAR) to determine code status. The DON confirmed that the resident's wishes were not consistently documented, as the physician orders did not match the signed DNR form. The facility's policy required that emergency care, including CPR, be provided according to physician orders and resident choice as indicated in advance directives, but this was not accurately implemented in this case.