F0578

K

Failure to Establish, Document, and Communicate Resident Code Status and Advance Directives

Rensselaer, New York Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were afforded their right to formulate advance directives, have corresponding physician orders for code status, and have those choices documented and communicated to staff. Facility policy required that advance directives be provided on admission, that residents’ wishes for code status be established before CPR through a code status identifier, and that the EMR contain a written MD order and a physical MOLST form. An additional policy required that upon admission and as needed thereafter, residents or their legal representatives be informed of their rights regarding advance directives, that the facility inquire about existing directives, and that the resident’s status be documented in the medical record. Despite these policies, surveyors found multiple residents without documented code status orders, without MOLST forms, and one resident with conflicting documentation of code status.

One resident with a history including wedge compression fracture, ischemic heart disease, and hypertensive heart disease was cognitively intact and had no documented physician order for basic life support interventions or code status in the record. When this resident was found unresponsive with low oxygen saturation and no obtainable blood pressure, staff initiated CPR and called 911. Nursing notes and a provider note documented that there was no MOLST or advance directive limiting resuscitation on file at the time of the event, and the NP instructed staff to treat the resident as full code. Interviews with two LPNs revealed they could not identify the resident’s code status, found no MOLST in the binder or code status in the EMR, and followed an understood practice of treating residents as full code when no directive was found. The NP stated a MOLST had been completed at admission and verified, but it was missing from the binder and the code status had not been entered into the EMR because the nurse manager was responsible for that task. The NP also did not document the code status in the admission physical because it was not on the resident’s EMR profile.

Additional residents were found without proper documentation of advance directives or code status. One resident with acute and chronic respiratory failure, COPD with acute respiratory infection, and interstitial pneumonitis was cognitively intact, had no MOLST form on the unit, no physician order for basic life support interventions, and no documented code status in the admission provider assessment; the resident and a family member reported that no admission paperwork or advance directive had been completed, though the resident stated a preference to be full code. Another cognitively intact resident with encephalopathy and acute respiratory failure had no physician order for basic life support interventions and no documented code status in the admission assessment; this resident reported not signing admission paperwork, did not know what advance directives were, and after explanation stated a preference for DNR. A further cognitively intact resident with acute respiratory failure, COVID-19 pneumonia, and acute pulmonary edema had no MOLST on the unit, no physician order for basic life support interventions, and no documented code status in the admission assessment, and did not recall signing admission paperwork or knowing about advance directives, later expressing a preference to be full code.

Another resident with traumatic ischemia of muscle, dehydration, and muscle weakness, and mild cognitive impairment, had conflicting documentation regarding code status. A MOLST form dated in late January documented that this resident was to have CPR and was signed by the NP several days later. However, physician orders for the same resident included an order entered by an RN for DNR/DNI, which was signed by the NP on a subsequent date. This created a direct conflict between the MOLST form indicating CPR and the physician order indicating DNR/DNI. Interviews with facility leadership confirmed that the facility’s practice was to treat residents as full code when no advance directive was in place and that code status orders were supposed to be matched to the MOLST form when entered into the EMR. The survey identified that for multiple cognitively intact residents, there was either no documented physician order for code status, no MOLST form, or conflicting documentation, leading to an Immediate Jeopardy finding and substandard quality of care for the affected residents.

Removal Plan

• The admission nurse was educated by the Administrator on their responsibilities to educate all residents/representatives on admission/re-admission of their right to formulate advance directives and to ensure a corresponding physician order for code status and/or a MOLST form are entered into the resident's medical record.
• The facility management team conducted a facility-wide audit of each current resident to ensure residents had physician orders for code status and/or a MOLST form.
• All residents without a MOLST had advance directives discussed with them or their representative by nursing staff.
• Corresponding MOLST forms and physician orders for advance directives were entered into the electronic medical record by the unit manager and approved by the Nurse Practitioner.
• The Administrator and Assistant Administrator reviewed the facility policy on advance directives and made no revisions.
• The facility initiated mandatory education for the Nurse Practitioner, all registered nurses, and a licensed practical nurse on the facility policy regarding educating all residents/representatives on admission of their right to formulate advance directives and ensuring a corresponding physician order for code status and/or a MOLST form are entered into the resident's medical record.
• Education was conducted verbally by the Nursing Supervisor and/or designee.
• Facility staff not reached by telephone would not be permitted to work until they received the education.