Failure to Follow Advance Directives Due to Code Status Documentation Errors
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately followed, resulting in a discrepancy regarding the resident's code status at the time of a critical event. The resident was admitted with multiple diagnoses, including muscle weakness, MRSA, acute abscess, delirium, atrial fibrillation, dementia, and mood disturbances. Documentation in the clinical record was inconsistent: while the hospital history and some admission documents indicated a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, other records, including a signed advance directive and physician orders, indicated a full code status. The care plan did not specify a code status, and there was no evidence that the code status was clarified with the resident, their power of attorney, or the physician. Shift reports and staff recollections further conflicted, with some indicating DNR and others full code. On the day of the incident, the resident was found unresponsive in bed. Staff interviews revealed that upon discovery, the CNA called for a nurse, and two nurses responded. One nurse checked the resident's vital signs, while another checked the chart for code status and reported the resident as DNR. As a result, CPR was not initiated. There was no documentation in the clinical record that CPR was started, and the facility's self-report confirmed that CPR was not performed when the resident was found unresponsive and without signs of life. The staff relied on conflicting information from shift reports and the physical chart, leading to the decision not to initiate resuscitation. Interviews with nursing staff and the Director of Nursing confirmed that the expectation was to verify code status in the physical chart and follow the documented orders. However, the DON acknowledged a breakdown in communication and misreading of the resident's code status. Facility policy required clear documentation and communication of advance directives, but this was not consistently implemented, resulting in the failure to honor the resident's documented wishes regarding resuscitation.