Failure to Update Care Plan Following Change in Advance Directive
Penalty
Summary
The facility failed to update or revise the care plan for a resident after a change in the resident's advance directive status. Record review showed that the resident had completed an Advance Directive Form indicating a Do Not Attempt Resuscitation (DNR) preference. However, the resident's care plan continued to reflect a Full Code status, instructing staff to initiate CPR if the resident's heart or breathing stopped. The care plan was not updated to reflect the resident's DNR status, despite facility policy requiring that changes in advance directives be incorporated into the care plan and communicated to the interdisciplinary team. The deficiency was identified through interviews and record reviews, including documentation of the resident's death and confirmation from the Social Service Director that the care plan should have been updated at the time of the code status change.