Failure to Document Advance Directive in Electronic Health Record
Penalty
Summary
A deficiency was identified when the facility failed to document a resident's code status in the electronic health record as required by facility policy. The resident in question had diagnoses including chronic obstructive pulmonary disease, anemia, and dysphagia, and was assessed as moderately cognitively impaired, requiring substantial assistance with daily activities. The resident's care plan and advance directives form indicated a do not resuscitate (DNR) status, but this information was not reflected in the physician's orders or the electronic health record. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that it is facility policy for advance directives to be entered into the electronic health record within 24 hours of admission. However, both staff members were unable to locate the resident's code status in the electronic system, and acknowledged that in an emergency, staff would have to refer to the physical chart. The facility's Advance Directives Policy requires that such directives be displayed prominently in the medical record, but this was not done for the resident in question.