Inconsistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that both the hard chart and the electronic medical record contained consistent and correct advance directive information for a resident. Specifically, the physician orders indicated the resident was a full code, while the hard chart documented the resident as Do Not Resuscitate Comfort Care Arrest (DNR CCA), and the care plan also reflected DNR CCA status. The Director of Nursing confirmed this discrepancy during an interview, verifying that the physician order was for full code, but the hard chart had a DNR CCA form signed by the physician. The resident involved was admitted with diagnoses including Parkinson's disease, muscle weakness, hypertension, other specified forms of tremor, and thrombocytopenia. The resident was assessed as cognitively intact, with a BIMS score of 15. Facility policy required that information about whether a resident has executed an advance directive be displayed prominently in the medical record, but this was not consistently done in this case, resulting in conflicting documentation regarding the resident's code status.