Failure to Properly Document and Maintain Advance Directives and DNR Orders
Penalty
Summary
The facility failed to ensure that Advance Directives, specifically Do Not Resuscitate (DNR) orders, were properly documented and maintained in the medical records for three residents. For one resident, there was no signed DNR Form DH1896 in the medical record, despite the resident returning from the hospital with a DNR status. Staff interviews revealed that although the change in code status was discussed and a verbal order was received, the required DNR form was never completed or signed by the appropriate parties, nor was it placed in the resident's chart. As a result, when the resident experienced a medical emergency, EMS was not provided with the valid DNR documentation, leading to the initiation of CPR against the resident's wishes as indicated by the verbal order and hospital documentation. Another resident's medical record contained both a full code order and a signed DNR Form DH1896, creating confusion regarding the resident's actual code status. Staff were observed to be uncertain about the resident's current status when reviewing the chart, as both orders were present and not properly updated. This improper documentation could have led to inappropriate interventions during a medical emergency. A third resident's DNR Form DH1896 was found to be incomplete, as it was signed by the provider but not by the resident or their representative, rendering the form invalid. Staff confirmed that the resident was capable of signing the form but was not asked to do so upon admission. The facility's policy required proper documentation and verification of Advance Directives, but these procedures were not followed, resulting in discrepancies and lack of clarity in residents' code status documentation.
Removal Plan
- A whole house audit was completed regarding advance directives and two identified variances were corrected.
- One code status was updated in the medical record, and it is clear to staff of the resident wishes and one next of kin validated the resident's advance directives with a signature.
- The Regional Nurse Consultant educated the clinical management team to the Code Status Response Policy.
- Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team on Code Status Response Policy.
- The morning clinical worksheet was updated.
- ADHOC Quality Assurance meeting was conducted to review the removal plan including the medical director.