Failure to Ensure Consistent Advance Directives for Code Status
Penalty
Summary
The facility failed to ensure that advance directives regarding code status were accurately reflected in the clinical record for one resident. Specifically, a review of the resident's clinical record showed a physician's order and care plan indicating Full Code status, while a Physician's Order for Life Sustaining Treatment (POLST) signed by the resident indicated a Do Not Resuscitate (DNR) status. This discrepancy meant that the resident's wishes as documented in the POLST were not aligned with the orders and care plan maintained by the facility. The Director of Nursing confirmed during an interview that the clinical record did not match the POLST signed by the resident. The deficiency was identified through clinical record review and interviews, and it was determined that the facility did not ensure appropriate advance directives were in place and consistent for the resident involved.
Plan Of Correction
Resident 114 code status was reviewed with resident/representative and confirmed desire for DNR status. Care plan, Physician order, and POLST reviewed and revised. Facility-wide audit of POLST, Physician order, and care plan was done to assure clinical record and POLST are consistent with residents' wishes. DON/Designee educated licensed nursing staff and social services staff on the importance of assuring POLST, Physician order, and care plan are consistent with residents' wishes. Random audits will be conducted of resident's clinical record to assure that POLST, Physician order, and care plan are consistent with residents' wishes. Audits will be done daily x 5 days, then weekly x 4, then monthly x 2 or until compliance is achieved. Results will be discussed in monthly QAPI meeting.