Inconsistent Documentation of Resident Advance Directives Across Medical Record
Penalty
Summary
The facility failed to ensure that residents’ advance directive wishes were consistently documented across the Electronic Health Record (EHR), MOST forms, physician orders, and care plans for multiple residents. For one resident, the EHR face sheet listed the code status as Attempt Resuscitation/CPR, the physician’s order directed Attempt Resuscitation/CPR, and the care plan documented the resident as Full Code, while the signed MOST form indicated the resident’s choice was Do Not Resuscitate (DNR). The DON confirmed that the MOST form conflicted with the face sheet, physician orders, and care plan, and acknowledged that all advance directive documentation should match throughout the chart. For a second resident, the admission record showed the resident’s entry into the facility, and the signed MOST form documented a choice of DNR, but the current physician orders directed Attempt Resuscitation/CPR and the care plan did not indicate any advance directive. For a third resident, the face sheet and MOST form both indicated DNR, but the physician’s orders listed the advance directive as Full Code/CPR and the care plan did not include any advance directive information. In interviews, the DON confirmed that the physician orders and care plans for these residents did not match the signed MOST forms and stated that this did not meet her expectations for consistent documentation of advance directives.
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