Failure to Ensure Accurate and Consistent Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that residents' advance directives were accurately documented, signed, and consistently reflected throughout their medical records. For one resident with schizoaffective disorder, dementia, and severe morbid obesity, the advance directive indicated Do Not Resuscitate Comfort Care - Arrest (DNRCC-Arrest), but the comprehensive care plan did not address this directive. Additionally, the DNR Identification Form was not signed or dated by a physician, and staff confirmed that without a physician's signature, CPR would be performed if the resident was unresponsive. The facility's policy required that advance directives be respected and displayed prominently, but did not address ensuring consistency between the electronic medical record and the DNRCC form. Similar deficiencies were found for two other residents. One resident with chronic obstructive pulmonary disease and paraplegia had conflicting advance directive information between the electronic and hard medical records, with staff and the DON confirming the inconsistency. Another resident with chronic obstructive pulmonary disease, dementia, and schizoaffective disorder had a care plan indicating DNRCC status, but the DNRCC form in the hard medical record was blank and not signed by a physician. Staff interviews revealed uncertainty about what actions to take in an emergency due to the lack of clear, signed documentation. These findings affected three residents reviewed for advance directives.