Failure to Document Resident Advance Directive and Code Status
Penalty
Summary
The facility failed to obtain and maintain written documentation of a resident's code status and advance directive in the medical record. Upon admission, the resident was noted to have multiple diagnoses, including type two diabetes mellitus, severe sepsis, cellulitis, rheumatoid arthritis, and atrial fibrillation. The admission summary indicated the resident was alert and listed as a full code, while a physician order documented a Do Not Resuscitate Comfort Care (DNRCC) status. However, a subsequent physician progress note again listed the resident as a full code. Review of both the electronic health record (EHR) and the hard copy medical record revealed no copy of an advance directive, although the hard chart was labeled with DNRCC on the outside and the EHR banner also indicated DNRCC. Interviews with facility staff confirmed that there was no signed advance directive in either the paper chart or the EHR for the DNRCC code status. The Quality of Life Coordinator stated that code status was discussed during care conferences, but could not provide documentation of a signed directive. The Administrator confirmed that the resident was admitted with a DNRCC code status according to received records, but later discussions with the resident and family revealed a preference for full code status. The facility's policy required obtaining and placing copies of all advance directives in the medical record, but this was not done for the resident in question.