Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were accurately and consistently documented for a resident with severe cognitive impairment. Record review showed discrepancies between the resident's MOLST form, which included orders for Do Not Resuscitate (DNR), intubation, ventilation, noninvasive ventilation, transfer to hospital, dialysis, artificial nutrition, and hydration, and the active physician orders, which only indicated DNR and Do Not Intubate (DNI). The resident's care plan referenced following the MOLST and noted a legal guardian was in place, but did not clarify the inconsistencies between the MOLST and physician orders. Interviews with nursing staff and the Director of Nurses confirmed that the MOLST form should be signed by the resident or health care proxy and that all medical record documentation, including physician orders, should match the MOLST form. However, the facility did not ensure that the resident's code status and advance directives were consistently documented across the medical record, leading to a deficiency in honoring the resident's right to have their treatment preferences accurately reflected.