Failure to Verify and Communicate Advance Directives Results in Lack of CPR
Penalty
Summary
The facility failed to establish and implement consistent mechanisms for documenting and communicating a resident's choice regarding advance directives to the staff responsible for care. One resident, who had a Medical Orders for Life Sustaining Treatment (MOLST) form indicating Full Code status, was found without a pulse and respirations. Staff did not initiate cardiopulmonary resuscitation (CPR) as required by the resident's documented wishes. Instead, staff relied on incorrect advance directive information entered into the electronic medical record, which stated Do Not Resuscitate (DNR)/Do Not Intubate (DNI), and did not verify the resident's current wishes with the resident, their representative, or the MOLST form. The deficiency was compounded by a series of documentation and communication failures. Upon the resident's readmission from the hospital, an LPN entered a DNR/DNI order into the electronic medical record based on unverified information from another staff member, without consulting the resident, their representative, or the physician. Another LPN confirmed the order without independent verification. The physician subsequently signed the order remotely, relying on nursing staff to have completed the necessary checks. There was no evidence that the MOLST form or the resident's current wishes were reviewed or validated during this process. When the resident was found unresponsive, staff checked the electronic medical record rather than the MOLST form, resulting in no CPR being initiated despite the resident's Full Code status. The Director of Nursing later confirmed that the MOLST form indicated Full Code, but CPR was not performed due to signs of irreversible death. The facility's failure to verify and accurately document advance directives placed all residents with such directives at risk and resulted in actual harm to the resident involved.