Failure to Consistently Complete and Document Advance Directives
Penalty
Summary
The facility failed to follow its own policy regarding the completion and documentation of residents' advance directives for four residents. In multiple cases, the required Medical Interventions Consent Form, which records a resident's choices for life-sustaining treatments and other medical interventions, was either missing from the clinical record or not signed by the resident or their representative. For example, one resident with diagnoses including paranoid schizophrenia and kidney cancer, who was cognitively intact, did not have a completed or signed consent form in the record, despite a physician order indicating CPR as the code status. Similarly, another resident with dementia and chronic kidney disease, who was moderately cognitively impaired, also lacked a signed consent form, even though a physician order for CPR was present. In another instance, a resident with severe cognitive impairment and multiple diagnoses had a Medical Interventions Consent Form completed by a representative via telephone, indicating comfort measures only and do-not-resuscitate/do-not-intubate status. However, after a psychiatric hospitalization and re-admission, there was a period during which no physician order for advance directives was present in the clinical record. Staff interviews revealed that the process for obtaining and documenting advance directives was inconsistent, with responsibilities split between nursing supervisors and social workers, and follow-up with representatives sometimes limited to leaving phone messages. Additionally, a resident admitted with sepsis, heart failure, and endocarditis, who was cognitively intact, did not have a code status order in place for eight days after admission. During this time, the resident would have been classified as full code and provided CPR by default. Staff interviews confirmed that code status should be established upon admission, and that verbal consent could be obtained if the resident was unable to sign. The facility's policy required that advance directives be reviewed with the resident or representative, documented on the consent form, and accompanied by a physician order, but these steps were not consistently followed.