Failure to Maintain Consistent Advance Directive Documentation
Penalty
Summary
A deficiency occurred when the facility failed to maintain accurate and consistent documentation of a resident's advance directive and code status throughout the medical record. The resident, who was cognitively intact and had diagnoses including chronic kidney disease and hypertension, was admitted with a code status of do not resuscitate (DNR) indicated in the electronic medical record profile. However, a review of the advanced care planning notes revealed the absence of an advance directive, and a Medical Orders for Scope of Treatment (MOST) form in the record stated 'attempt CPR' and 'full scope of treatment.' Additionally, there was no physician's order addressing the resident's code status. Staff interviews confirmed the inconsistency, with the Social Worker and Director of Nursing both unable to explain the discrepancy between the electronic record and the MOST form. The resident herself stated her wish to have a DNR code status, but the documentation in her medical record did not consistently reflect this preference. The deficiency was identified through record review and staff interviews, highlighting a lack of accurate and unified documentation regarding the resident's advance directive and code status.