F0578

D

Inconsistent Advance Directive Documentation and Missing DNR Forms

Hickory, North Carolina Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The facility failed to maintain accurate and consistent documentation of advance directives across the medical record and related reference tools for two residents. For one cognitively intact resident, the care plan initiated on 04/18/25 documented a full code status with interventions to call 911 and initiate all life-sustaining measures if the resident’s heart or breathing stopped. However, the medical record contained a physician’s order dated 01/12/26 for Do Not Resuscitate (DNR), and a DNR form dated the same day was present in the advance directive binder at the nurse’s station. The MDS Coordinator stated it was the MDS nurse’s responsibility to update care plans when new orders were written and acknowledged that the resident’s care plan should have been revised on 01/13/26 after review of new orders, but this was missed.

For another resident with severe cognitive impairment, the physician’s orders and care plan documented a DNR status, and the EMR banner also indicated DNR. The facility maintained an advanced directives notebook at the nurse’s station for quick reference in emergencies, but this resident’s DNR form was not present in the notebook. A nurse reported that in an emergency she would check both the EMR and the notebook, and if no DNR form was in the notebook, she would determine the resident to be full code. The unit manager and DON explained that DNR forms were to be completed on admission, kept in the notebook, and sent with the resident to the hospital, with the receiving nurse responsible for verifying the form’s return and the unit manager responsible for weekly checks. They indicated the resident’s DNR form likely did not return from a recent hospital transfer and had not been replaced or identified as missing, resulting in the absence of the DNR form in the notebook despite an active DNR order.