Failure to Maintain Accurate and Updated Advance Directive Information
Penalty
Summary
The facility failed to ensure that updated and accurate advance directive information was maintained for a resident. The resident, who had diagnoses including cerebral infarction, major depressive disorder, and dysphasia, was dependent on staff for transfers and toileting. Upon review of the resident's medical record, there was a discrepancy between the code status displayed at the top of the record, which indicated DNR (do not resuscitate), and a signed Medical Treatment Decision Form in the record that indicated the resident requested full resuscitation (CPR) in the event of cardiac or respiratory arrest. Interviews with facility staff revealed that the resident had changed their mind regarding code status, but the updated form was uploaded by the social worker without notifying nursing staff, resulting in the code status not being updated in the medical record. The facility's policy requires that any decision-making regarding a resident's choices be documented in the medical record and communicated to the interdisciplinary team and staff responsible for the resident's care. This failure led to conflicting information regarding the resident's advance directives.