Failure to Maintain Accurate Advance Directive Documentation at Time of Death
Penalty
Summary
The facility failed to ensure that accurate and clear advance directives were in place for a resident at the time of death. The resident, who had multiple complex diagnoses including severe cognitive impairment, was admitted to hospice care, and a change in code status from full code to DNR-CCA was initiated. However, there was no hospice documentation, including the updated advance directive, present in the facility's medical records at the time of the resident's death. Staff interviews revealed that nurses were aware a change in code status was pending but had not received the signed documentation from hospice. When the resident was found without vital signs, staff checked the electronic medical record and, finding no update, initiated CPR in accordance with the existing full code order. During resuscitation, hospice staff called to inform them of the new DNR-CCA status, leading to confusion and the cessation of CPR. EMS, also lacking documentation of the code status change, resumed CPR upon arrival. The facility's policies required that advance directives and DNR orders be clearly documented and accessible in the resident's medical record. Both the Administrator and DON confirmed that the necessary hospice documentation, including the updated advance directive, had not been received or filed in the facility. This lack of documentation led to confusion among staff during a critical event and resulted in actions that were not aligned with the resident's most current wishes.