Failure to Properly Document and Maintain Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that code status was properly assessed, documented, and accessible in the medical record for two residents reviewed for advance directives. For one resident admitted with a history of stroke, right-sided weakness, hypertension, anxiety, aphasia, and dysphagia, the electronic medical record indicated "Full Code" status on the face sheet and medication records, but there was no care plan for code status and no documented assessment of code status preferences in the "Documents" tab. The code status assessment form was only completed and signed by the social worker after the deficiency was identified, and not by the resident. Interviews with staff revealed that the code status assessment was missed during the admission process and that there was confusion regarding responsibility for completing the assessment. For another resident with cerebral infarction, dysphagia, diabetes, hemiplegia, hemiparesis, and vascular dementia, who was enrolled in hospice and had a legal guardian, the care plan indicated DNR and hospice services. However, the DNR order form in the medical record was not signed by a physician as required, and the previous DNR order had expired. The social worker confirmed that the DNR order was not current and that it was their responsibility to ensure the form was accurately completed and signed. Facility policy required annual review and physician signature for DNR orders, which was not followed in this case. The facility's own policy specified that advance directives and code status forms should be obtained, signed, and placed in the medical record upon admission, with annual review and re-signing as necessary. In both cases, the required documentation and signatures were either missing or incomplete, resulting in a lack of clear, accessible, and current information regarding the residents' code status and advance directives.