Failure to Accurately Formulate and Document Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives were properly formulated and accurately documented for two residents. For one resident, the electronic medical record (EMR) indicated a do not resuscitate (DNR) status, but there was no evidence in the medical record that the resident had signed and dated an advance directive, and staff confirmed there was no documentation of the resident electing DNR status. For another resident, the EMR listed a full code status, but a CPR designation form signed and dated by the resident indicated a preference for no CPR, and staff confirmed that the EMR did not reflect the most recent election of no CPR. Review of facility policy showed requirements for inquiry and documentation of advance directives upon admission and ensuring the plan of care is consistent with documented treatment preferences, which were not followed in these cases.