Failure to Update Care Plan with Accurate DNR Status
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised to accurately reflect the resident's advance directive code status. Specifically, the care plan for one resident continued to indicate 'Full Code' despite multiple sources in the resident's medical record, including physician orders, an Advance Directive Consent, and a Louisiana Physician Order for Scope of Treatment (LaPOST), all documenting a Do Not Resuscitate (DNR) status. This discrepancy was identified through interviews and record reviews, where both the Minimum Data Set (MDS) staff member and the Director of Nursing (DON) confirmed that the care plan was inaccurate and should have been updated to reflect the resident's DNR status. The resident involved had a medical history that included Alzheimer's disease, cerebral vascular disease, and cerebral infarction. The facility's own policies require that care plans be reviewed and revised periodically to ensure consistency with the resident's written plan of care and advance directives. Despite these requirements, the care plan was not updated to match the documented DNR status, resulting in an inaccurate representation of the resident's wishes and physician orders.