Failure to Update Care Plan Following Change in Advance Directive Status
Penalty
Summary
The facility failed to revise the care plan for a resident after a change in advance directive status from Full Code to Do Not Resuscitate (DNR), as ordered by the physician. The resident, who had diagnoses including sequelae of cerebrovascular disease and malignant neoplasm of a urinary organ, had a MOST form and medical transfer form both indicating DNR status. However, the care plan continued to document the resident as Full Code, despite the physician's order and supporting documentation reflecting the DNR status. Record reviews and staff interviews confirmed that the care plan was not updated to reflect the change in advance directive status. The Director of Nursing acknowledged that the care plan should have been revised when the physician's order changed the resident's status, and that the MDS Nurse was responsible for updating the care plan upon notification of such changes. The deficiency was identified through review of documentation and staff interviews, which revealed a lack of timely revision to the care plan in accordance with the resident's current advance directive status.