Failure to Honor and Document Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that advance directives were honored and properly documented in the medical records for three residents reviewed for code status. One resident, who had a documented preference for Do Not Resuscitate (DNR) status, was found unresponsive by staff and subsequently received cardiopulmonary resuscitation (CPR) both at the facility and during transport to the emergency room. Staff did not inform the Emergency Medical Team (EMT) of the resident's DNR status, and the required signed DNR Form DH1896 was not present in the resident's chart or provided to EMS. Interviews with staff revealed that although the resident returned from the hospital with a DNR order, the process to complete and file the official DNR form was not followed, and the form was never signed or placed in the chart. As a result, EMS initiated full resuscitation efforts, which were continued in the emergency department. Further review of two additional residents' records revealed similar documentation failures. One resident's chart contained both a full code order and a signed DNR form, leading to confusion about the resident's actual code status. Another resident's DNR form was signed by the provider but not by the resident or their representative, rendering the form invalid. Staff interviews confirmed that the process for verifying, documenting, and updating code status orders was inconsistently followed, and that required forms were either missing, incomplete, or not properly filed in the residents' medical records. The facility's policy required that code status and advance directives be verified on admission, documented in the medical record, and that the appropriate state-specific forms be completed and placed at the front of the resident's chart. However, the observed failures included lack of timely completion and filing of DNR forms, lack of communication with families or responsible parties to confirm code status changes, and the presence of conflicting orders in the medical record. These actions and inactions resulted in residents' wishes regarding resuscitation not being honored and created confusion among staff during emergency situations.
Removal Plan
- A house wide audit was completed verifying advanced 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.
- Regional Nurse Consultant provided education to 100% of the clinical management team related to Advanced Directives.
- Licensed Nurses were educated by the Director of Nursing and the facility clinical administration team related to Advanced Directives, reviewing AD/CS orders, process for completing a DNR order and honoring a resident choice, code blue process and placement of code status in resident hard chart at 97%.
- The Regional President completed the Essential Core Functions: Resident care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Nursing Home Administrator.
- The Director of Risk Management completed the Essential Core Functions: Resident Care and Quality of Life, Human Resources, Physical Environment and Atmosphere and Leadership and Management with the Director of Nursing.
- Code Blue drills started and completed each shift.
- ADHOC Quality Assurance meeting was conducted to review the removal plan including the medical director.