Failure to Clearly Document Advance Directives in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directives were clearly documented and accessible in the medical record. Record review showed that the resident, who had severe cognitive impairment and multiple diagnoses including Alzheimer's disease, was admitted to hospice care. Despite this, there was no documentation of advance directives, code status, or DNR orders in the designated sections of the electronic medical record, the orders section, or the care plan. The only evidence of a DNR order was found as a PDF uploaded multiple times to various non-standard sections of the electronic record, and there was no DNR documentation in the physical medical record binder or behind the Advance Directive tab. The printed face sheet incorrectly indicated that no advance directives were selected for the resident. Staff interviews confirmed that the facility's practice was to keep advance directives and code status documentation in the front of the resident's physical chart, and in the absence of such documentation, the resident would be considered a full code. This was reiterated even for residents on hospice care. The resident's emergency contact confirmed the resident's DNR-CC status, but this was not reflected in the accessible medical record or care plan as required by facility policy, which states that the DON or designee must ensure appropriate orders are documented in the medical record and plan of care.