Inconsistent and Incomplete DNR and Advance Directive Documentation
Penalty
Summary
The deficiency involves the facility’s failure to properly complete, maintain, and reconcile advance directive and DNR documentation for multiple residents. For one resident admitted with a physician order for Do Not Resuscitate (DNR), the EMR banner and physician orders reflected a DNR status, but there was no corresponding DNR form in the advanced directives notebook at the nurse’s station. Nursing staff reported that, in an emergency, they would rely on the EMR and the advanced directives notebook to determine code status. The DON confirmed that a DNR form should have been present in the notebook for this resident and stated that the Social Worker was responsible for completing advance directive forms at admission and auditing the notebook, but the prior Social Worker had left and it was unclear whether the family had been consulted or a DNR form completed. Another resident had conflicting code status information across the medical record. The EMR contained a physician order for DNR, but the resident’s care plan documented Full Code status, and a physician progress note also listed the advanced directive status as Full Code Blue. The quarterly MDS indicated this resident was cognitively intact. The code status notebook at the nursing desk contained no advanced directive information for this resident. The Administrator and DON both stated that advanced directive information should match throughout the record and that the Social Worker was responsible for initiating and auditing this paperwork, but the Social Worker had recently resigned. Staff interviews showed that nurses and the Unit Manager relied on either the EMR profile page or the code status notebook, depending on accessibility, and expected these sources to match. A third resident had discrepancies between hospital documentation, physician orders, and paper advance directive forms. The hospital discharge summary and a physician order in the facility EMR both indicated a DNR status, and a physician progress note documented “Do Not Attempt Resuscitation (DNR/no CPR).” However, the MOST form in the code book, signed by the resident’s Responsible Party (RP), indicated a preference for attempted CPR, and the Advanced Directive Discussion Document also indicated CPR. The MOST form lacked a physician signature. The resident, who had moderately impaired cognition per the admission MDS, stated that he and his RP had decided he would not want CPR. The Director of Sales and Marketing/admission Coordinator, who had been completing advance directive paperwork in the absence of a Social Worker, reported that the RP had chosen CPR on both forms and that she placed these documents in the code notebook rather than in the physician’s folder for review and signature. The DON verified that the physician’s DNR order did not match the paper forms in the code notebook and acknowledged the missing physician signature on the MOST form.
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