Inconsistent Advance Directive Documentation for Two Residents
Penalty
Summary
The facility failed to ensure that residents' wishes regarding advance directives were clearly established and consistently reflected in both the physical and electronic medical records for two of four residents reviewed. For one resident, the physical chart contained a POLST form signed by both the physician and the resident, indicating a desire for CPR but a refusal of intubation (DNI). However, the electronic medical record and active physician orders instructed staff to implement Full Code treatment without any restriction on intubation. Staff interviews confirmed that in the event of a medical emergency, they would follow the electronic orders, which did not reflect the resident's DNI preference. Similarly, another resident's physical chart included documentation that a POLST was completed with the resident and her son, designating CPR with limited interventions and a DNI order. The POLST was signed by the physician and the resident's responsible party. Despite this, the electronic medical record and active physician orders indicated Full Code treatment without any restriction on intubation. Staff confirmed that, based on the electronic orders and absence of a physical chart indicator, they would provide Full Code CPR without honoring the DNI preference. These discrepancies were reviewed with facility leadership during the survey.