Failure to Honor and Document Resident's Advance Directive Code Status
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive and code status were accurately documented and honored. The resident, who was severely cognitively impaired and had diagnoses including diabetes, dementia, muscle weakness, depression, and breast cancer, was admitted with a Do Not Resuscitate; Comfort Care (DNRCC) order according to her wishes and those of her son, who was her Power of Attorney. However, during a medical emergency when the resident was found unresponsive, the LPN checked the electronic record and found no information regarding Advance Directives. Upon reviewing the physical chart, the LPN found a yellow sheet indicating Full Code status and initiated CPR, also calling emergency services. The resident's son was notified and arrived after the resident had expired. It was only discovered days later that the resident was actually a DNRCC at the time of the incident. Further review revealed that after a care conference with the resident's son, the Social Service Designee faxed the DNRCC form to the nurse practitioner, who signed and placed it in the physical chart. The Social Service Designee also notified an RN to update the order, but there was no physician's order for the DNRCC in the resident's chart, nor was the code status updated in the electronic record. The facility's policy required that residents' Advance Directive wishes be honored and documented, with appropriate physician orders written for those choosing Advance Directives. This failure to accurately document and communicate the resident's code status led to the initiation of CPR against the resident's documented wishes.