Failure to Maintain Clear Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that residents' advance directives were clearly maintained and accurately documented in their medical records. For two residents with complex medical histories, including conditions such as diabetes, dementia, schizoaffective disorder, multiple sclerosis, and respiratory failure, there were inconsistencies in the documentation of their code status. In both cases, the residents' paper charts contained conflicting documents: one indicating Do Not Resuscitate Comfort Care (DNRCC) and another, signed by a physician, indicating Do Not Resuscitate Comfort Care-Arrest (DNRCC-A). During interviews, the Divisional Director of Clinical Operations confirmed the presence of both DNRCC and DNRCC-A documents in the residents' charts. Facility policy required that copies of advance directives be placed in the hard chart medical record, and defined the differences between DNRCC and DNRCC-A. However, the presence of both types of documentation for each resident created ambiguity regarding the residents' actual code status, demonstrating a failure to maintain clear and consistent records as required by facility policy.