Failure to Maintain Current Hospice DNR in Medical Record and Code Status Discrepancy at Time of Death
Penalty
Summary
The deficiency involves the facility’s failure to maintain the most current and accurate advance directive in a resident’s medical record and to ensure that the documented code status matched the resident’s actual wishes as established through hospice. The resident had multiple diagnoses including muscle wasting and atrophy, depression, dementia with behavioral disturbance, dysphagia, hypertension, and diffuse large B-cell lymphoma, and was cognitively impaired per the admission MDS. The physician’s orders and care plan in the facility record documented the resident as "full code" with an advance directive for CPR, and the plan of care specified that the advance directive and code status would be honored and kept in the medical record at all times. No updated advance directive orders were found in the facility record after the resident’s admission to hospice. Hospice documentation showed that upon hospice admission, hospice staff discussed advance directives with the resident’s wife, who stated they did not want CPR or other life-sustaining measures if the resident’s heart or lungs stopped, and a DNR order (DNR-CC) was completed and signed by the wife. Hospice staff reported that these documents are typically faxed to the facility, and hospice records reviewed by the hospice RN showed a DNR-CC advance directive in place. However, the facility’s medical record continued to list the resident as full code, and the CNP confirmed that only full code status was evident in the facility’s documentation. The Administrator and DON were informed of the discrepancy between the facility’s documentation and the hospice DNR-CC documents and did not dispute the findings. On the day of the resident’s death, multiple staff interactions occurred while the facility record still reflected full code status. Hospice staff reported the resident was actively dying, transferred him from his wheelchair to bed, and made him comfortable. A CNA later found the resident unresponsive and reported this to a nurse; no code was called. An agency RN, who administered Morphine per hospice direction, noticed the full code status on the MAR and reported it to the unit manager/LPN, who told her not to worry about the code status and that it would be taken care of. Hospice staff documented that the resident expired and that CPR was not initiated, consistent with the hospice DNR-CC directive, but this directive was not present or reflected in the facility’s medical record as required by the facility’s advance directive policy, which calls for obtaining, filing, and communicating current advance directives and updating physician orders and the care plan accordingly.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.