Failure to Accurately Document and Align Resuscitation Preferences
Penalty
Summary
The facility failed to accurately document and align a resident's resuscitation preferences in the medical record, resulting in a discrepancy between the Medical Orders for Scope of Treatment (MOST) form and the physician's order. The resident, who had multiple diagnoses including dementia, diabetes, atrial fibrillation, hypertension, heart disease, dysphagia, and osteoporosis, was severely cognitively impaired and required varying levels of assistance with daily activities. The physician's order clearly indicated a Do Not Resuscitate (DNR) status, reflecting the wishes of the resident or their representative. Upon review, the resident's MOST form, completed at admission, was marked 'Yes' for CPR, indicating a desire for resuscitation, while the physician's order and other documentation, such as psychosocial assessments and care conference notes, consistently indicated DNR status. Additionally, the MOST form's Section B was marked for comfort-focused treatment, which conflicted with the requirement that a 'Yes' for CPR should be paired with full treatment to prolong life. The care plan did not specify the resident's CPR wishes, and the hospital transfer form referred to the MOST form, which was inaccurately completed. Staff interviews revealed a lack of consistent training and understanding regarding the completion and review of MOST forms. Nurses responsible for completing the forms reported minimal training and uncertainty about review frequency. The DON acknowledged the confusion caused by the incorrectly completed MOST form and confirmed that the nurse who completed it was new and no longer employed at the facility. As a result of the documentation error, the resident received CPR in the emergency room, contrary to the physician's DNR order, due to the conflicting information presented on the MOST form.