Failure to Honor Full Code POST Orders During Resident’s Decline and Unresponsiveness
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s Physician Orders for Scope of Treatment (POST) and advance directives requiring full code and full interventions. The resident had a POST form completed in accordance with state requirements, signed by the resident, specifying CPR with resuscitation efforts including mechanical ventilation, defibrillation, and cardioversion, and full medical and surgical interventions with the goal of sustaining life by all medically effective means. The resident’s MDS admission assessment documented a BIMS score of 15, indicating intact cognition, and a physician determination of capacity confirmed that the resident demonstrated capacity to make decisions. The resident’s care plan reflected activation of the resident’s advanced directive as full code, including full treatments and tube feeding as indicated, with a goal that the resident’s wishes as expressed in the advance directive would be followed. Progress notes show that the resident experienced a decline in condition over time, including decreased participation in therapy, increased weakness, poor oral intake, fatigue, low blood pressure, refusal of medications, and a coccyx wound with odor. On one date, staff expressed concern to the PA that the resident remained full code despite this decline. The PA documented that the resident, who had decision-making capacity, was counseled about prognosis and offered hospice and comfort measures; the resident declined and explicitly chose to remain full code with heroic efforts to sustain life. Subsequent documentation noted that medications were held due to the resident’s decline in condition. On a later date, a progress note documented that the resident remained on a steady decline, was unresponsive to sternal rub and other physical stimuli, had an irregular increased pulse of 124, and was having difficulty breathing. The physician attempted to contact the resident’s son multiple times to change the POST to DNR status but was unable to reach him, and staff continued to monitor and document changes rather than initiate full code interventions in accordance with the existing POST. A subsequent progress note indicated that the family later notified staff that the resident was unresponsive, at which point an LPN started chest compressions and an AED was applied, and EMS assumed care and administered emergency medications before time of death was called. In interview, the DON and ADON acknowledged they were aware the POST specified full code and full interventions, stated they called the son for direction because they believed the resident could not make decisions on the date of death, and admitted that the resident’s directive was not followed.
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.