Failure to Ensure Consistent Documentation of Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure accurate and consistent documentation of a resident's advance directives and code status. Record review showed that the resident, who had moderate cognitive impairment, had conflicting information regarding her wishes for cardiopulmonary resuscitation (CPR). Her advance directive, signed by the resident, indicated she did not want CPR, while a separate CPR Statement of Decision form, signed by her power of attorney and physician, indicated she did want CPR. The electronic medical record (EMR) listed her as do not resuscitate (DNR), and her physician had ordered DNR status in the EMR. However, the paper chart contained the conflicting CPR Statement of Decision form, and staff referenced both the paper chart and EMR to determine code status. Interviews with nursing staff revealed confusion regarding which document reflected the resident's true wishes, as the paper chart and EMR did not match. Staff indicated that the CPR Statement of Decision form was reviewed quarterly with the family, but discrepancies persisted. The director of nursing confirmed that code status should match in both the EMR and paper chart. Facility policy stated that advance directives would be honored and that residents have the right to formulate such directives, but the inconsistent documentation led to uncertainty about the resident's actual code status.