Failure to Honor Resident's Advance Directive Due to Documentation Errors
Penalty
Summary
The facility failed to ensure that a resident's right to formulate and have their advance directive honored was upheld. Upon admission, the resident, who had a history of acute and chronic respiratory failure with hypoxia, interstitial pulmonary disease, pulmonary hypertension, COPD with acute exacerbation, and pneumonia, had a Colorado Medical Orders for Scope and Treatment (MOST) form completed and signed by the resident's representative and a nurse practitioner. This form clearly indicated the resident's wishes to receive CPR in the event of cardiac or respiratory arrest. However, the facility incorrectly transcribed the resident's code status as 'Do Not Resuscitate' (DNR) in the electronic medical record (EMR), care plan, medication administration record (MAR), and nurses' report sheet, which conflicted with the signed MOST form. When the resident was found unresponsive and without vital signs by a CNA and subsequently assessed by an LPN and an RN, staff did not initiate CPR or contact emergency medical services. The LPN and RN both relied on the information from the nursing report sheet, which incorrectly listed the resident as DNR, rather than referencing the MOST form or the EMR for the accurate code status. As a result, the resident's expressed wishes for resuscitation were not honored, and no resuscitative efforts were made prior to the physician pronouncing death. Interviews with staff confirmed that the nurses did not check the MOST form binder or the EMR to verify the resident's code status at the time of the incident. Instead, they relied on outdated or incorrect information from the report sheet. The facility's failure to ensure accurate and consistent documentation of the resident's advance directives directly led to the staff not attempting resuscitation, contrary to the resident's documented wishes.