Failure to Accurately Document Advance Directive Status
Penalty
Summary
The facility failed to ensure that a resident's current advance directive was accurately documented in the medical record. Record review showed that the resident's face sheet listed a Do Not Resuscitate (DNR) order, while the New Mexico Medical Orders For Scope of Treatment (MOST) form indicated the resident was a Full Code, meaning they desired lifesaving procedures such as CPR. During an interview, the Unit Manager confirmed that the resident's code status had been changed to Full Code on the MOST form following an audit, but this update was not reflected in the resident's medical records, which continued to show DNR status. This discrepancy in documentation could lead to confusion regarding the resident's wishes for emergency and lifesaving care, as the medical record did not match the most current advance directive indicated on the MOST form.