Failure to Obtain and Document Advance Directive and Code Status Upon Admission
Penalty
Summary
The facility failed to obtain and document an advance directive, including code status information, upon admission for one resident with a diagnosis of acute respiratory failure with hypoxia. Review of the admission progress note revealed that there was no mention of the resident's advance directive or code status. The admitting nurse stated she had not been shown the full process for completing a new admission and learned procedures informally from other nurses. She admitted that she did not ask about the resident's code status during the admission process. Interviews with the former DON and the Administrator confirmed that the admitting nurse was responsible for reviewing and initiating the resident's advance directive and code status upon admission, but this was not completed. The DON indicated that the process should involve the nurse and, if available, the Social Worker, with communication to the NP or MD for orders. The MD stated that code status is typically obtained from hospital paperwork and confirmed with the resident. The Administrator acknowledged that the admission paperwork, including the advanced directive, was not completed for this resident.