Failure to Maintain Clear and Accessible Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directives were clear and easily accessible to staff. Specifically, the medical record for a resident with a history of kidney transplant complications, end stage kidney disease, and diabetes mellitus showed inconsistencies regarding code status. The hospital paperwork indicated the resident was to be Full code, while the advance directive form in the facility's records had DNRCCA selected and was signed by a physician but not dated. Additionally, the form had a hospital sticker, further complicating the clarity of the resident's code status. Interviews with staff and the resident's family confirmed the confusion, as the Corporate Registered Nurse acknowledged the presence of both a Full code hospital document and an undated DNRCCA form. The facility's policy required staff to check the chart for code status, but the lack of a dated, clearly documented directive led to uncertainty. This deficiency was identified during a complaint investigation and affected one resident out of three reviewed for advance directives.