Failure to Consistently Update and Match Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that advance directive information was consistently updated and matched across all relevant documentation for two residents. For one resident, there was a discrepancy between the physician's order, which indicated Do Not Resuscitate (DNR), and both the face sheet and Medical Orders for Scope of Treatment (MOST) form, which indicated full code status. Staff interviews revealed that the resident's code status had recently changed from DNR to full code, but the physician's order was not updated to reflect this change. Both the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) acknowledged that the orders should have been updated to match the resident's current wishes as documented on the MOST form and face sheet. For another resident, the physician's order indicated full code status, while the face sheet, DNR form, and MOST form all indicated DNR status. This resident was cognitively intact at the time of admission. Staff interviews confirmed that the advance directive information in the physician's order was not updated when the DNR form was signed by the physician. Both the ADON and DON stated that all documentation should have matched to accurately reflect the resident's advance directive wishes, but the necessary updates were not made in the system.