Inconsistent Advance Directive Documentation for a Resident
Penalty
Summary
The facility failed to ensure that advance directive information was accurate and consistent throughout the medical record for a resident. The resident's electronic health record (EHR) contained conflicting physician orders regarding code status, with one order indicating Do Not Resuscitate (DNR) and another indicating Full Code. The resident's care plan also listed the code status as Full Code, while the Advance Directives binder at the nursing station contained both a signed DNR form and a Medical Orders for Scope of Treatment (MOST) form indicating Full Code. The DNR form was signed by a physician and had no expiration date, while the MOST form was signed by both the resident and the physician. Staff interviews and observations revealed further inconsistencies and confusion regarding the resident's code status. The Social Worker and a nurse both identified the presence of the outdated DNR form in the Advance Directives binder but did not remove it, instead placing it back in the binder after review. The nurse stated she would check the EHR and MOST form to confirm code status, while the resident himself stated he was a DNR. The Director of Nursing acknowledged that the code status information in the Advance Directive binder and the EHR should match, but this was not the case for this resident.