Failure to Accurately Document and Communicate Resident's DNR 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. The resident, who had intact cognition and diagnoses including delusional disorders and COPD, expressed a clear desire not to be resuscitated if found without a pulse or respirations. Despite this, the electronic medical record (EMR) and the paper chart contained conflicting information, with some documents indicating a full code (CPR) and others indicating Do Not Resuscitate (DNR). The resident had communicated his wishes to the health unit coordinator (HUC), who completed a new POLST form indicating DNR, but this form was awaiting a physician's signature and had not yet been reflected in the EMR or on the face sheet/banner. Staff interviews revealed inconsistent practices and communication regarding changes in code status. The HUC stated that the process was to update the EMR first and then the paper chart, but the code status would not officially change until the physician signed the POLST. The HUC did not notify nursing staff directly, relying instead on progress notes and the 24-hour report, which nurses were expected to review before each shift. Nursing staff, including LPNs, indicated that in an emergency, they would check the paper chart or the EMR for code status, and would perform CPR if the documentation indicated full code, regardless of any pending changes or verbal requests from the resident. The facility's policy required immediate notification of the physician and documentation of any verbal refusal of CPR, with the resident's wishes to be honored until a written order was obtained. However, in this case, the process was not followed, and the resident's verbal request for DNR was not promptly communicated to the provider for a verbal order, nor was it immediately updated in all relevant records. As a result, there was a significant risk that the resident would have received CPR against his wishes in the event of an emergency, due to the lack of accurate and timely documentation and communication among staff.