Failure to Accurately Document and Communicate Advance Directives
Penalty
Summary
The facility failed to ensure that residents' advance directives and code status were accurately documented and consistently communicated across all relevant sections of the medical record for two residents. For one resident, the medical record contained conflicting information, with the resident header and physician's order indicating Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH) status, while the care plan and special instructions listed Full Code status. The code status binder also contained both a Full Code face sheet and a portable DNR form for this resident. Staff interviews confirmed the presence of these discrepancies and clarified that the resident's current code status was DNR, not Full Code. For the second resident, the physician's order indicated DNR status, but the care plan listed Full Code status. Documentation from the resident's guardian authorized a DNR/DNI order, but the care plan was not updated to reflect this change. Staff interviews confirmed that the care plan did not match the physician's order. These inconsistencies demonstrate a failure to adhere to facility policy regarding the accurate and timely documentation and communication of residents' advance directives and code status.