Failure to Document and Verify Code Status and Advance Directives on Admission
Penalty
Summary
The facility failed to implement its policies and procedures regarding residents' rights to determine their code status and complete advance directives upon admission. Specifically, for two of three sampled residents, nursing staff did not verify or document the residents' wishes regarding Cardiopulmonary Resuscitation (CPR) at the time of admission. Review of the facility's policy indicated that a POLST form and code status order should be completed and documented during the admission assessment, and the resident's wishes should be communicated to the physician to obtain appropriate orders. However, for one resident, there was no order for code status in the medical record at admission, and the POLST form was not present in the chart until after discharge. For another resident, there was no order for code status, and neither a POLST nor an advance directive was found in the medical record. During interviews and record reviews, the administrator confirmed that the required documentation for code status and advance directives was missing for both residents at the time of admission, contrary to facility policy. The absence of these documents meant that staff did not have clear guidance on the residents' wishes regarding life-sustaining treatment, such as CPR, at the time of admission.