Failure to Accurately Document and Implement Resident Advance Directives
Penalty
Summary
The facility failed to accurately document, order, and care plan a resident's wishes regarding advance directives for life-sustaining treatment. Record review showed that the resident's signed advance directive specified a do not resuscitate (DNR) status with a trial course of intubation and ventilation for five days. However, the electronic health record (EHR), care plan, and physician orders all reflected a DNR/do not intubate (DNI) status, which did not align with the resident's documented wishes. During an interview, the Assistant Unit Nurse Manager confirmed that the resident's advance directive indicated DNR with a trial of intubation for five days, and acknowledged that the current documentation, orders, and care plan did not reflect these wishes.