Failure to Document and Communicate Residents' Advance Directives
Penalty
Summary
The facility failed to ensure that all residents' wishes regarding emergency and lifesaving care, including code status, medical interventions, and artificial hydration/nutrition, were obtained, documented, and communicated to staff. Record reviews for multiple residents revealed that the Advanced Directives sections of their Face Sheets were left blank, and their electronic health records did not contain documentation of their preferences for medical interventions or artificial hydration/nutrition. These residents had significant medical histories, including chronic kidney disease, acute kidney failure, hypertensive heart disease, aphasia, hemiplegia, hemiparesis, Alzheimer's disease, unspecified convulsions, acute respiratory failure, and myocardial infarction. During an interview, the Admissions Director confirmed that the facility did not have records of residents' wishes regarding full code status, medical interventions, or artificial hydration/nutrition for those without an advance directive. The Admissions Director stated that residents are only asked about advanced directives during admission and that there is no regular review or additional documentation for residents who do not already have an advance directive. The only documentation completed is an emergency medical services DNR form for residents with a DNR status, which does not include information about other medical interventions or artificial hydration/nutrition.