F0578

D

Inconsistent Advance Directive Documentation for Two Residents

Scottsdale, Arizona Survey Completed on 08-07-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that advance directives were accurately completed and consistently maintained in the clinical records of two residents. For one resident with multiple diagnoses including hypertension, hyperlipidemia, epilepsy, schizoaffective disorder, intracranial injury with loss of consciousness, and major depressive disorder, a physician’s order documented full code status. However, a pre-hospital medical care directive signed by the resident indicated that the resident did not want CPR and was DNR. Despite this, the face sheet and care plan both listed the resident as full code, while the care plan goal stated that the resident’s end-of-life wishes would be honored.

For a second resident with extensive medical conditions including kyphosis, hypertension, Type 2 DM with neuropathy, spinal stenosis, atherosclerotic heart disease, vascular dementia, mood disturbance, GERD, hyperlipidemia, anxiety disorder, COPD, dysphagia, and major depressive disorder, both a VA Advance Directive and a pre-hospital medical care directive signed by the resident documented DNR status and refusal of CPR. In contrast, the face sheet, care plan, progress notes, and a physician’s order all identified this resident as full code. Staff interviews confirmed that advance directives are initiated on admission and reviewed quarterly, that staff are expected to check both physical and electronic charts for code status, and that a specific form is required to document changes with updates to the EHR by medical records. The DON confirmed that discrepancies existed in both residents’ records and acknowledged that this could result in residents’ end-of-life wishes not being honored, contrary to facility policy on advance directives.