Mismatch Between Advance Directives, MOST Forms, and EHR Code Status Orders
Penalty
Summary
Surveyors identified that the facility failed to ensure residents' current advance directives and New Mexico Orders for Scope of Treatment (MOST) forms matched the code status orders in the electronic health record (EHR) for two residents. For one resident, the face sheet showed admission on a specified date, and the physician orders in the EHR documented the resident as Full Code for advance directive code status. However, the resident's current advance directive and MOST form, signed on a later date, indicated the resident had chosen Do Not Resuscitate (DNR). During an interview, the DON confirmed that this resident's code status should be DNR and not Full Code, acknowledging the inaccuracy and that staff had not updated the resident's code status in the EHR. For another resident, the admission record showed admission on a specified date, and the current medical orders included an order, dated on a specific day, to not attempt resuscitation due to DNR status. In contrast, the resident's MOST form, dated on another specific day, documented that the resident chose to be Full Code and wanted CPR performed if needed. In an interview, the DON stated that this discrepancy did not meet her expectations because the resident's medical order should match the MOST form, but it did not. The report states that this deficient practice is likely to result in confusion, delay, and residents not having their wishes honored if a life-threatening event occurred.
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