Failure to Implement and Document Advance Directives on Admission
Penalty
Summary
The facility failed to ensure that advance directives were properly implemented upon admission for one resident. Upon admission, the resident was provided with conflicting information regarding their code status: acute care transfer orders indicated full code status (to perform CPR), while the advance directives in the electronic health record (EHR) indicated no CPR. The admission nurse did not validate the transfer order with the resident for accuracy, and the process for confirming and documenting the resident's wishes was not followed. The required Physician Order for Life Sustaining Treatment (POLST) form was not completed, and there was no documentation in the EHR clarifying the resident's CPR status. Interviews with staff revealed that the process for discussing and documenting advance directives was not streamlined. The nurse practitioner responsible for discussing advance directives with new admissions was unaware of the resident's existing directives and could not recall why the POLST form was not completed. The director of nursing confirmed that the order for CPR should have been entered into the EHR and that conflicting information should have been clarified with the physician, but there was no evidence this occurred. This failure resulted in the resident's advance directives not being honored as required by policy and state regulations.