Failure to Accurately Communicate and Transmit Advance Directive During Hospital Transfer
Penalty
Summary
The facility failed to ensure accurate communication of a resident's advance directive information during a transfer to the hospital. An older male resident with Alzheimer's disease, COPD, BPH, hypertension, and hyperlipidemia had a valid Directive to Physicians and Family or Surrogates on file that elected all treatments other than those needed to keep him comfortable be withheld, and specified no ventilator and no feeding tube. Despite this, his physician orders and care plan documented him as Full Code, with interventions including initiation of BLS/CPR if without a heartbeat. On the transfer form completed for his hospital transfer, the section on advance directives incorrectly indicated that the resident had a DNR, which directly contradicted both the Full Code status in his orders and care plan and the content of his directive. A copy of the advance directive was not provided to EMS or hospital staff at the time of transfer. The LVN who completed the transfer form acknowledged that she made an error by marking DNR and confirmed that the resident was Full Code at that time. She also stated she should have provided EMS with a copy of the advance directive to send with the resident. The resident’s responsible party reported having reminded the discharge nurse to send the advance directive with the resident. The physician stated he expected nursing staff to relay appropriate advance directive information and provide hard copies of documents on all transfers. Subsequent observation found the resident in bed with a bandage at the tracheal site indicating intubation tubing had been removed, and he was non-responsive to verbal or tactile stimuli. The facility’s policy on Self Determination End of Life Measures stated that the facility would respect residents’ wishes as outlined in advance directives and that the primary nurse would note resuscitation status on all applicable clinical records and document whether an advance directive had been executed, which was not accurately carried out in this case.
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