Inconsistent and Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that advance directives and code status documentation were complete, accurate, and consistent with the residents' wishes and the electronic health record (EHR) for three of twenty sampled residents. In one case, a resident expressed a clear refusal of any tubes for care, including catheters and feeding tubes, yet the EHR listed the resident as full code with full treatment, and the available POLST forms were inconsistent and not properly signed by a physician. One POLST was not on file in the EHR, and no verbal physician order was documented to support the code status. For another resident, the POLST indicated a do not resuscitate status, but the required signature of the patient or decision maker was only documented as a verbal order without a follow-up physician signature. In a third case, the POLST and EHR code status did not match, and the POLST lacked a physician signature, with no verbal physician order found in the EHR. Staff interviews revealed that unsigned POLST forms were entered into the electronic record before being properly signed, contrary to facility policy and POLST instructions, which require patient or legal decision maker signatures and provider follow-up for verbal orders.