Failure to Update Advanced Directives in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advanced directives were accurately updated and reflected in the medical record. The resident, who had multiple diagnoses including right hip fracture, cognitive communication deficit, metabolic encephalopathy, chronic kidney disease, chronic obstructive pulmonary disease, congestive heart failure, and atrial fibrillation, had a care plan indicating the presence of advanced directives. However, the care plan did not specify the details of these directives. The interventions listed included reviewing advanced directives quarterly and as needed, maintaining code status as ordered, and honoring the durable Power of Attorney's (POA) decisions. Despite a current physician's order indicating the resident was to be a full code, an out-of-hospital DNR form had been completed and signed by the resident's POA and physician, indicating the resident did not want CPR and wished to have a DNR code status. Interviews with nursing staff and the ADON confirmed that the code status in the electronic medical record should have been updated upon receipt of the signed DNR form, but this was not done. Facility policy required confirmation of code status and obtaining a physician's order as part of the medical record, which was not followed in this instance.