Failure to Maintain Consistent Advance Directives
Penalty
Summary
The facility failed to establish clear and consistent advance directives for one resident. Clinical record review showed that the resident had a physician's order dated May 28, 2025, indicating a DNR (do not resuscitate) status, meaning no CPR should be performed if the resident had no pulse and was not breathing. However, a POLST (Pennsylvania Orders for Life Sustaining Treatment) form dated May 7, 2025, and signed by the resident, indicated that the resident desired to be a full code, meaning CPR should be attempted under the same circumstances. There was no documented evidence that the resident completed an updated POLST after May 7, 2025, nor was there any documentation of discussions with facility staff or the physician indicating a change in the resident's wishes regarding life-sustaining treatment. This lack of documentation and clarity regarding the resident's advance directives was confirmed during an interview with the Nursing Home Administrator and Director of Nursing.
Plan Of Correction
1. Resident 28's Advanced Directive was immediately clarified with resident and signed by MD. Information was updated in resident orders, special instructions, and Care Plan. Resident 28's Advanced Directive was uploaded into electronic medical record. 2. An audit of all residents' POLST was completed to ensure resident order, special instructions, and Care Plan matched wishes expressed on signed POLST form. 3. All new or amended POLST forms will have an order immediately entered in PCC. Care Plan and special instructions will be updated. Any new/amended POLST will be uploaded to the "Document" tab in residents' electronic medical chart. All Licensed Staff will be educated on immediately entering/amending order, special instructions, and Care Plan based on POLST form. All existing resident POLST will be uploaded into residents' electronic record. 4. Audits will be conducted of any admissions or updated POLST, daily 4x a week, weekly for 4 weeks, and monthly x2 by the Administrator/designee to ensure compliance. Results of the audits will be presented at the QAPI meetings for review and to ensure ongoing compliance.