Failure to Accurately Reflect DNR Status in Medical Record
Penalty
Summary
The facility failed to accurately incorporate a resident’s directive for life-sustaining treatment into the medical record when a completed and signed POLST form documented a DNR (do not resuscitate) order, but multiple parts of the record continued to identify the resident as full code. During an interview, the SSD stated that the resident was full code and that the family had revoked the DNR status, but when the SSD and surveyor reviewed the SSD’s progress notes together, there was no documentation that the DNR had been revoked. The SSD also acknowledged that neither the resident’s care plan nor the face sheet had been updated to reflect any change in code status. At the time of review, the face sheet, care plan, and physician order sheet all listed the resident as full code despite the signed DNR on the POLST form. The facility’s advance directives policy required that advance directives, including CPR and POLST forms, be included in the plan of care, reviewed during care plan meetings, and that any oral revocation be documented in the health record with time, date, and place, which had not been done in this case. This deficiency affected one resident whose advance directive for life-sustaining treatment was not consistently or accurately reflected across the medical record, including the care plan, face sheet, and physician orders, and for whom there was no documented evidence of revocation of the existing DNR order as required by facility policy.
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