Failure to Accurately Document and Update Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that advance directives, specifically code status and resuscitation wishes, were accurately documented and updated in the electronic health record (EHR) banner, physician orders, and the Physician's Orders for Life Sustaining Treatment (POLST) for two residents. For one resident with diagnoses including congestive heart failure, hypertension, renal failure, diabetes, and chronic respiratory failure, the POLST signed by both the resident and the medical provider indicated a full code status, meaning the resident wished to receive cardiopulmonary resuscitation (CPR). However, the EHR banner and physician orders incorrectly reflected a do not resuscitate/do not intubate (DNR/DNI) status. Multiple staff interviews confirmed that in the event of an emergency, staff would have followed the incorrect DNR/DNI status in the EHR and not performed CPR, contrary to the resident's expressed wishes. A similar issue was identified for another resident with diagnoses including diabetes with polyneuropathy, hypothyroidism, hypertension, and chronic kidney disease. This resident's POLST and Directives to Define Scope of Medical Care form, both signed by the resident and provider, indicated a wish to be resuscitated (full code). However, the EHR banner and order summary incorrectly listed the resident as DNR. Staff interviews revealed that in an emergency, staff would have referred to the EHR and not initiated CPR, again contrary to the resident's wishes. The process for updating and verifying code status orders was inconsistent, with reliance on both the EHR and physical binders, leading to discrepancies and confusion among staff. The facility's policy required that advance directives and code status be discussed at admission and reviewed at care conferences, but the process for ensuring that changes were accurately reflected in all relevant documentation was not followed. The case manager was responsible for entering provider-signed orders into the EHR, but this step was missed, resulting in outdated or incorrect information being available to staff. Staff training and understanding of where to find the most current code status information varied, contributing to the risk of not honoring residents' wishes regarding life-sustaining treatment.
Removal Plan
- Completed an audit of all residents' code status.
- Reviewed the process to ensure the entered POLST information into the EMR was accurate and updated.
- Educated licensed staff regarding the updated POLST procedure and where to find a residents' code status.
- Continued education for staff.