Failure to Update Advance Directive Order in Resident's Medical Record
Penalty
Summary
A deficiency occurred when the facility failed to properly transcribe and update a change in advance directive order for one resident. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 12, was initially documented as a full code upon admission, meaning they wished to receive CPR. However, the resident later expressed a desire to change their code status to Do Not Resuscitate (DNR) Comfort Care, and signed the appropriate DNR order form. Despite this, the resident's electronic health record (EHR) and current orders continued to reflect full code status, and the change was not updated in the EHR as required. Interviews with staff revealed that the process for updating code status involved multiple roles, including the Director of Social Services (DSS), nursing staff, and the medical records nurse. The DSS and DON both stated that the change in code status should have been communicated and documented in the EHR, but this was missed during a period when the facility did not have a DSS. The former medical records nurse did not upload the DNR form or update the EHR, resulting in the resident's code status remaining incorrect in the medical record.