Failure to Ensure Consistent Documentation of Resident's Resuscitation Wishes
Penalty
Summary
The facility failed to ensure that a resident's wishes regarding resuscitation were accurately and consistently documented across all areas of the medical record. For one resident with moderately impaired cognition and multiple diagnoses, including Ehlers-Danlos Syndrome and COPD, there were discrepancies in the documentation of code status. The resident's face sheet and physician's orders indicated Do Not Resuscitate (DNR), while the Physician's Order for Life Sustaining Treatment (POLST) form indicated both Cardiopulmonary Resuscitation (CPR) and DNR. Interviews with the resident confirmed her wish not to receive life-saving measures. Multiple nursing staff and the director of nursing reported that the POLST is the primary document referenced for code status in the event a resident is found unresponsive. Staff acknowledged that if the POLST contained conflicting instructions, such as both CPR and DNR, they would seek clarification from a nurse manager or compare the POLST to the face sheet in the electronic medical record. Facility policy stated that the physician order status and POLST should be followed in resuscitation situations. The presence of conflicting documentation in the resident's records created confusion among staff regarding the appropriate action to take, and the error was not corrected at the time of the survey.