Failure to Accurately Document and Implement Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directive wishes were accurately documented and implemented. There was a discrepancy in the resident's records: the face sheet and care plan listed the resident as full code, while a signed Out-of-Hospital Do Not Resuscitate (OOH-DNR) order was found in the miscellaneous documents section. Additionally, there were no DNR orders in the electronic health record, and the resident's orders reflected hospice care with contradictory information regarding code status. The resident had not signed any consents for hospice or the OOH-DNR, and the last care plan meeting did not include the resident. Interviews with facility staff, including the social worker, DON, and administrator, confirmed awareness of the discrepancies and acknowledged that the resident's wishes were not accurately reflected or updated in the records. The facility's policy requires that the medical record and plan of care reflect the resident's wishes and physician orders, but this was not followed in this case. The resident, who had moderate cognitive impairment and required supervision for daily activities, expressed during an interview that he would want CPR if needed, further highlighting the inconsistency between his stated wishes and the documented directives.