Failure to Document Advance Directive Choices in Physician Orders
Penalty
Summary
The facility failed to ensure that a physician's order was present to reflect a resident's wishes regarding cardiopulmonary code status, hospitalization, and intravenous fluids, as indicated in the resident's advance directive. The resident in question had diagnoses including dementia, hypertension, and muscle weakness, and was identified as having severely impaired cognition and requiring maximal assistance with daily activities. The care plan and an Advance Directive Consent Form, signed by the responsible party and physician/APRN, clearly documented the resident's election for full code status (CPR), hydration by IV fluids, nutrition by feeding tube, hospitalization to prolong life, and antibiotic therapy, with a refusal of comfort measures. Despite these documented choices, a review of the physician's orders over the relevant period did not reveal any orders addressing the resident's code status or the other elected interventions. Interviews with nursing staff and facility leadership confirmed that the code status should be reflected in the physician's orders and that it is the responsibility of nursing supervisors to ensure these orders are obtained and entered into the electronic medical record. The facility's own policy also requires that the physician write appropriate orders to indicate code status, to be verified by nursing upon admission. However, this process was not followed, resulting in the absence of required physician orders for the resident's advance directive choices.