Failure to Implement Advanced Directive Care Plan for Full Code Resident
Penalty
Summary
The facility failed to implement the Advanced Directive care plan for a resident who was designated as Full Code, resulting in CPR not being performed when the resident was found without a pulse or respirations. The resident had a documented history of cerebral atherosclerosis, dysphagia, gastro-esophageal reflux disease, anemia, constipation, hypertension, and hyperlipidemia. The clinical record, physician's orders, and care plan all specified that the resident was to be a Full Code and that resuscitation (CPR) should be attempted. The resident was also admitted to hospice services, but the POLST form and care plan continued to specify Full Code status. On the day of the incident, staff discovered the resident deceased and documented the absence of pulse and respirations, but there was no evidence that CPR was attempted as required by the care plan and physician's orders. Interviews with staff, including the DON, revealed a misunderstanding among nursing staff, who believed that hospice admission automatically changed the resident's code status to DNR, despite clear documentation to the contrary. The deficiency occurred during a shift change, and the DON confirmed that no resuscitation efforts were made.