Failure to Honor Resident's Advance Directive Preferences
Penalty
Summary
The facility failed to ensure that advance directives accurately reflected a resident's current preferences regarding life-sustaining treatment. According to the facility's policy, the POLST (Practitioner Order for Life-Sustaining Treatment) form should be completed or reviewed with the resident and/or their legal representative and updated periodically to reflect the resident's wishes. For one resident, the POLST form and care plan documented a Do Not Resuscitate (DNR) status, but there was no evidence in the clinical record that any discussion had occurred with the resident regarding their code status preferences. During an interview, the resident, who was documented as cognitively intact on both admission and quarterly MDS assessments, stated that no one had asked about their wishes in the event of cardiac or respiratory arrest and clearly expressed a desire for full resuscitation efforts. The Social Service Director reported that code status is typically discussed with residents or their representatives, but in this case, decisions were made by the state guardian without documented input from the resident, despite the resident's capacity to make such decisions.