Inconsistent Advanced Directive Documentation in Resident Medical Record
Penalty
Summary
The facility failed to ensure that accurate advanced directive information was consistently present throughout the medical record for one resident. The resident in question had multiple complex diagnoses, including severe cognitive impairment, and was unable to make decisions independently. A review of the resident's records revealed discrepancies: the electronic medical record and its banner indicated the resident was a Full Code, while the care plan and a signed physician DNRCC-A (Do Not Resuscitate Comfort Care Arrest) form indicated a DNRCC-A status. The care plan detailed specific interventions consistent with DNRCC-A, and the DNR form was filed in the electronic medical record. Interviews with nursing staff and the DON confirmed the inconsistency between the electronic medical record's code status and the care plan documentation. Staff reported that the electronic medical record banner is the primary source for verifying code status, which could lead to confusion in an emergency. The DON and Senior Administrator acknowledged the discrepancy and attributed it to issues with data transfer during a recent change in the electronic medical record platform.