Failure to Accurately Document and Communicate Residents' Advance Directives
Penalty
Summary
The facility failed to ensure that residents' code status and advance directive wishes were accurately documented and communicated in the medical records for five residents. In one case, a resident who was on palliative care with a POLST indicating comfort measures only was transferred to the emergency department, and the incorrect POLST was sent with the resident. The error was only identified after the transfer, and the emergency department was notified of the mistake. Progress notes and interviews confirmed that the resident's updated POLST had been completed months prior, but the documentation and communication did not reflect the resident's current wishes at the time of the transfer. For four additional residents, the medical records contained physician orders regarding advance directives (either DNR or CPR), but there was no documentation that the facility had discussed code status with the residents or their representatives. In one case, the resident was not capable of making their own decisions and had a guardian, but there was still no evidence of discussion or documentation. An administrative nurse confirmed that staff are expected to discuss and document code status at admission and care conferences, but acknowledged that the required documentation was missing in these cases.