Failure to Accurately Document and Confirm Advance Directive After Hospitalization
Penalty
Summary
A deficiency occurred when a resident's advance directive wishes were not accurately identified and documented after returning from a hospital stay. The resident's electronic medical record (EMR) listed his code status as 'Intubate Only,' while two signed Do Not Resuscitate (DNR) documents were present in both his EMR and paper chart, each signed by the resident, a provider, and a facility agent. The resident's care plan also indicated DNR status, and during an interview, the resident confirmed he believed his code status was DNR and expressed that he did not want to be intubated again after a previous experience. A licensed practical nurse (LPN) confirmed the discrepancy between the paper chart (DNR) and the EMR (Intubate Only), stating she would follow the highest level of care listed, which was 'Intubate Only.' The nurse supervisor updated the EMR to 'Intubate Only' after the resident returned from the hospital, based on a change observed during the hospital stay, but did not discuss this change with the resident. The director of nursing (DON) stated that any code status change after hospitalization should be confirmed with the resident, and that code status is reviewed at care conferences. The failure to confirm and accurately document the resident's code status led to the deficiency.