Failure to Update and Reconcile Advance Directives in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurate and up to date in the electronic medical record. Specifically, one resident's CPR preference form indicated a desire for full code status (to receive CPR), while the electronic medical record and physician orders reflected a DNR (Do Not Resuscitate) status. This discrepancy was identified during a review of the resident's records and confirmed through interviews with nursing staff, who acknowledged that the resident's code status should be consistent across all documentation. The facility's policy requires that information about advance directives be prominently displayed and updated in the medical record, and that changes be communicated to the interdisciplinary team and reflected in the care plan. Despite this, the resident's updated CPR preference was not entered into the electronic medical record, resulting in conflicting documentation. Staff interviews confirmed awareness of the need for consistency between the resident's expressed wishes and the medical record, but the necessary updates were not made at the time the new preference was obtained.