Failure to Update EMR to Reflect Resident’s Current Advance Directive and Code Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s current advance directive and code status were accurately and consistently documented in the electronic medical record (EMR). The facility’s policy on Advance Directives states that a resident’s choice about advance directives will be respected, including Do Not Resuscitate (DNR) orders. One resident was admitted and re-admitted with multiple diagnoses, including hemiplegia and hemiparesis following cerebral infarction, acute chronic systolic congestive heart failure, and hypertensive heart and chronic kidney disease with heart failure. The admission record documented the resident’s code status as DNR, and the care plan reflected that the resident/family desired DNR status, with interventions to follow facility protocol for DNR and not resuscitate the resident per resident/family request. The Annual MDS showed a BIMS score of 10, indicating moderately impaired cognition. Subsequently, physician orders and POLST forms in the record showed conflicting code statuses over time. There was a physician order for Full Code that was later discontinued, followed by an order for DNR, and the EMR header documented the code status as DNR. One POLST documented DNR/Allow Natural Death, while a later POLST documented Full Code/Attempt Resuscitation and was signed by a physician and the resident. The Social Services Assistant confirmed that the later Full Code advance directive should have rendered the prior DNR directive null and void and acknowledged that the EMR had not been updated to reflect the current Full Code status. The Interim DON confirmed that the EMR still showed a DNR order and DNR status in the header despite a current Full Code advance directive on file, and stated she had inadvertently discontinued the wrong advance directive and entered the DNR order in error. The Unit Manager confirmed that staff rely on the EMR orders and banner/header to determine a resident’s advance directive and that, for this resident, staff would see DNR in both locations while the current status was actually Full Code.
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