Inconsistent Resuscitation Orders and Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that a resident's documented wishes regarding resuscitation were accurately reflected and consistently maintained in both the physician's orders and the resident's Resuscitation Authorization. Specifically, a review of the clinical record for a resident with diagnoses including diabetes, chronic obstructive pulmonary disease, and high blood pressure revealed a signed Do Not Resuscitate (DNR) order in the Resuscitation Authorization, while the physician's orders indicated Full Code status, which would require initiation of CPR in the event of cardiac or respiratory arrest. During interviews, the resident confirmed a desire not to receive CPR and to allow natural death, which was not aligned with the current physician's order. The Director of Nursing acknowledged that the physician's orders and the Resuscitation Authorization were inconsistent and confirmed that both should accurately reflect the resident's advance directive wishes. This inconsistency was identified through review of facility policy, clinical records, and staff interviews.