Failure to Ensure Advance Directives Are Accessible to Staff and EMS
Penalty
Summary
The facility failed to ensure that residents' advance directives were readily accessible to staff and Emergency Medical Services (EMS) personnel, as evidenced by observations, interviews, and record reviews. In several cases, residents had documented wishes regarding resuscitation and code status, but the necessary paperwork, such as signed Do Not Resuscitate (DNR) forms, was either missing from the electronic health record or not available in the code status binders at the nurses' stations. This deficiency affected four residents who had varying degrees of cognitive impairment and significant medical histories, including dementia, atrial fibrillation, chronic obstructive pulmonary disease, and congestive heart failure. One resident with severe cognitive impairment and a DNR order experienced a critical event where EMS was called due to low oxygen saturation. When EMS arrived, staff were unable to provide a valid, physician-signed DNR form, resulting in the initiation of CPR and transport to the hospital, contrary to the resident's documented wishes. The resident was revived at the hospital, and only after family confirmation was care de-escalated, and the resident passed away. Interviews with nursing staff confirmed the absence of the required DNR documentation at the time of the emergency. For other residents, reviews of their medical records and code status binders revealed similar issues: either the signed DNR paperwork was not present in the electronic health record or not available in the code status book at the nurses' stations. Staff interviews confirmed that the required documentation was missing, and facility policy required that copies of all advance directives be placed in the medical record and, if applicable, a DNR order be obtained from the physician. The lack of accessible advance directive documentation directly impacted the facility's ability to honor residents' wishes regarding life-sustaining treatment.