Failure to Update Care Plan After Change in Advanced Directives
Penalty
Summary
The deficiency involves the facility’s failure to update a resident’s care plan to reflect a change in advanced directives. Record review showed that the resident was admitted with an advanced directive of Full Code status, and the care plan documented a focus on advanced directives with an established CPR (Full Code) order and corresponding initiation and creation dates. However, the resident’s code status was changed in October to Do Not Resuscitate (DNR), and this change was not reflected in the resident’s care plan. During interviews, the DON acknowledged that the resident’s care plan was not updated after the code status changed from Full Code to DNR. The MDS LPN stated that when a code status order changes, the care plan should be updated and that this is typically discussed in morning meetings before care plans are revised, but in this case the update did not occur. The Social Worker Director reported attending morning clinical meetings where advanced directives are reviewed and stated that if the care plan was not updated, it was likely missed during this process. Review of the facility’s “Advanced Directives Code Status” policy confirmed that when code status changes, Social Services and nursing must document the change and update the code status/advanced directives care plan, which did not happen for this resident.
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