F0578

D

Conflicting Advance Directive Documents for a Resident’s Code Status

Greensboro, North Carolina Survey Completed on 01-10-2026

Penalty

No penalty information released

Summary

The facility failed to maintain accurate and consistent advance directive information for one resident when conflicting code status documents were kept in the paper advance directive binder at the nursing station. The resident, who had cancer, generalized muscle weakness, and moderately impaired cognition, had a bright yellow/orange Do Not Resuscitate (DNR) form in the binder indicating DNR status with no expiration date. The same binder also contained a Medical Order for Scope of Treatment (MOST) form signed by the resident’s Nurse Practitioner that directed staff to attempt cardiopulmonary resuscitation (CPR) if the resident had no pulse and was not breathing. At the same time, the resident’s electronic medical record contained a physician’s order for full code/CPR, and the care plan documented the resident as a full code.

The Social Worker reported that she was responsible for obtaining advance directives at or shortly after admission, reviewing them with the resident or family depending on cognition, and then placing the signed forms in the provider’s box for review, after which nursing staff were responsible for documenting and retaining the orders. The nurse assigned to the resident stated that in an emergency she would look for advance directive information either in the 3-ring binder at the nursing station or in the EMR, indicating reliance on both sources. During interviews, the Social Worker acknowledged the potential for confusion caused by having both the DNR and MOST forms in the binder, and the DON and Regional Nurse Consultant confirmed that the DNR form should not have been in the binder and likely came from the hospital, yet it remained stored with the resident’s advance directive documents, creating inconsistent and contradictory information regarding the resident’s code status.