Inconsistent Documentation of Resident Code Status and Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively intact resident’s advance directive and code status were consistently and accurately documented across all parts of the medical record. The resident had a MOST (Medical Orders for Scope of Treatment) form in the Advance Directives binder, signed by the resident and physician, indicating “Attempt to Resuscitate (Full Code).” However, the outside of the resident’s binder had a yellow DNR sticker, which staff used to identify residents who had elected DNR status. In contrast to the MOST form, the resident’s EHR contained an active physician order indicating DNR status, and the advance directive information under the EHR Demographics tab and Physician Orders also reflected DNR. The resident’s annual MDS assessment documented that the resident was cognitively intact, and the advance directive care plan identified the resident as DNR. During interview, the resident stated he had previously discussed code status with staff and clearly expressed that his wishes were to be Full Code. He reported that he had not told anyone he wished to be DNR and did not recall signing paperwork for DNR status. Despite this, the MDS nurse stated that the resident was a DNR per physician order and acknowledged she was responsible for updating the care plan but could not explain why the resident’s code status had not been updated to reflect the resident’s wishes and the MOST form. The Social Worker reported that code status was verified on admission and discussed at baseline care plan meetings, and that a prior audit of code statuses had been conducted due to earlier inconsistencies. She stated that at the most recent care plan meeting for this resident, code status was discussed and the resident remained DNR, although progress notes and care plan meeting notes from that date contained no documentation that code status was discussed. The Social Worker acknowledged that the MOST form had not been updated to reflect the resident’s expressed wishes and that this was an error, stating it had been overlooked by the physician and nursing staff. The physician confirmed he was responsible for advance directive orders, that the resident was cognitively capable of making his own decisions, and that the discrepancy between the MOST form (Full Code) and the EHR and DNR orders had been overlooked. The DON and Administrator both acknowledged that the resident’s code status should have been consistent across the EHR, advance directive binder, and physician orders, but could not explain how the discrepancy occurred.
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