Failure to Update Care Plan to Reflect Resident’s DNR Status
Penalty
Summary
Surveyors identified that the facility failed to update a resident’s care plan to reflect the resident’s current advance directive wishes. A registered nurse (V4) stated that the resident (R41) was DNR, and R41’s Illinois Department of Public Health Uniform Practitioner Order for Life-Sustaining Treatment (POLST) form documented “NO CPR: Do Not Attempt Resuscitation (DNAR)” with selective treatment. R41’s face sheet and physician orders also indicated DNR status. Despite these documents, R41’s comprehensive care plan, dated later, continued to list the resident as FULL CODE, indicating that resuscitation should be attempted. The Director of Nursing (V2) stated that residents’ care plans should be updated whenever there are changes to the residents’ plan of care. Facility policies in the Health Care Policies Manual specify that care is subject to physician orders and the resident’s advance directives, and the Comprehensive Person-Centered Care Planning Manual requires that the care plan be consistent with resident rights and describe services not provided due to the resident’s exercise of the right to refuse treatment. The same policy requires the interdisciplinary team to review and revise the comprehensive care plan after each assessment. Despite these requirements, the facility did not revise R41’s care plan to align with the documented DNR/DNAR status and associated advance directive wishes.
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