Failure to Consistently Update Advance Directive Information in Medical Records
Penalty
Summary
The facility failed to maintain consistent and updated advance directive information throughout the medical record for one resident. The resident's medical record contained conflicting documentation regarding code status, with an advance directive form indicating Do Not Resuscitate (DNR) status, while a more recent form indicated full code status. Despite the resident being cognitively intact and clearly expressing a desire to be full code during an interview, the electronic medical record and medication administration record continued to display DNR status. Staff interviews revealed that the process for updating advance directive information involved multiple steps and personnel, including the social worker, medical records clerk, and MDS assistant, but communication breakdowns led to delays and inconsistencies in updating the resident's code status across all records. The social worker described the process for handling advance directives, which included assessing cognitive status, obtaining necessary signatures, and forwarding the completed form for scanning and record updates. However, the medical records clerk and MDS assistant each believed it was the other's responsibility to update the electronic medical record banner, and the physician was uncertain about whether she had documented the change in a progress note or written a new order. The medical records clerk initially stated he was not notified of the change, but later recalled being informed and notifying the MDS assistant, though the update was still not made in the system. As a result, the resident's current wishes regarding resuscitation were not accurately reflected in all parts of the medical record, leading to confusion among staff who relied on the electronic banner and medication administration record for code status information. The lack of a clear, coordinated process for updating and communicating changes to advance directives contributed directly to the deficiency identified during the survey.