Failure to Maintain Accurate and Complete Advance Directive Documentation
Penalty
Summary
The facility failed to maintain accurate and consistent advance directive information for several residents, as evidenced by discrepancies and incomplete documentation in both paper and electronic medical records. For one resident, the paper record contained a signed Medical Orders for Scope of Treatment (MOST) form indicating a Do Not Resuscitate (DNR) status, but the electronic health record and physician orders listed conflicting code statuses, including both DNR and Full Code. Interviews with nursing staff and management confirmed that the process for updating code status was not followed correctly, resulting in outdated and conflicting information remaining in the resident's records. Additionally, three other residents had MOST forms in the advance directive binders that were not properly signed by the resident or their representative. In one case, the form indicated verbal consent from a representative but lacked documentation of the date, time, or the identity of the person who obtained the consent. The social worker responsible for advance directives stated that she believed signatures were optional based on the form's language, and when verbal consent was obtained, she did not consistently document the required details. The DON and Administrator both confirmed that signatures and complete documentation are required for these forms. The affected residents included individuals who were both cognitively intact and severely cognitively impaired, with diagnoses such as paraplegia, chronic pain, Parkinson’s disease, chronic kidney disease, end-stage renal disease, and diabetes mellitus. The deficiencies were identified through record reviews and staff interviews, revealing a pattern of incomplete or inconsistent documentation of advance directives and code status across multiple residents.