Failure to Accurately Reflect Resident's Advanced Directive in EMR
Penalty
Summary
A deficiency occurred when a resident with diagnoses including atherosclerotic heart disease, congestive heart failure, and anxiety had a signed Do Not Resuscitate (DNR) order in their paper chart, but the Electronic Medical Record (EMR) incorrectly listed the resident as full code. The resident's care plan acknowledged an established advanced directive, but interventions were documented to support the resident's wish to receive CPR, which conflicted with the signed DNR. The quarterly assessment indicated the resident was moderately cognitively impaired and required moderate assistance with daily activities. During observation, surveyors found the EMR did not match the resident's signed advanced directive. The Director of Nursing Services (DNS) confirmed that nursing staff rely on the EMR for code status and was unsure why the records did not match. The DNS stated that the EMR should be updated as soon as an advanced directive is signed and that it is the responsibility of the nursing team, including herself and physicians, to ensure this is done. The facility's policy requires a physician's order for DNR to be placed in the EMR, but this was not done prior to the surveyor's inquiry.