Failure to Timely Update and Honor Resident's Advanced Directive
Penalty
Summary
The facility failed to timely update a resident's end-of-life wishes in the medical record, resulting in the advanced directive not being followed. The resident, who had severe cognitive impairment and multiple diagnoses including acute respiratory failure, diabetes, malnutrition, intellectual disabilities, and adult failure to thrive, required assistance with all decision-making. The legal guardian provided a new Provider Orders for Life Sustaining Treatment (POLST) form indicating do not attempt resuscitation (DNR) and comfort-focused treatment, and sent it to the facility's social worker. However, the facility's process required the provider to sign the POLST for it to be valid, and this signature was not obtained in a timely manner. As a result, the resident's medical record and provider orders continued to indicate full code status, and the resident was transferred to the hospital and treated as a full code when found unresponsive. Staff interviews confirmed that the new POLST was received but not processed due to the lack of a provider signature, and the code status in the medical record was not updated. The facility's policy required support and facilitation of residents' rights to request or refuse treatment and to formulate advanced directives, but this was not carried out in this instance.