F0578

D

Failure to Maintain Accurate and Accessible Advance Directives and Code Status Orders

Globe, Arizona Survey Completed on 02-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that valid, consistent, and readily accessible advance directives and medical orders were in place and accurately reflected for multiple residents, resulting in conflicting code status information and missing documentation. For one resident with diagnoses including malignant neoplasm of the prostate, acute kidney failure, hypothyroidism, glaucoma, benign prostatic hyperplasia, and muscle weakness, a POLST form documented a choice of no CPR and selective treatment to avoid intensive care and resuscitation efforts. Despite this, an active order in the clinical record listed the resident as full code, and staff were unable to locate the required prehospital medical care directive (orange advance directive form) in either the electronic health record or the nursing station binder at the time of review. The DON later acknowledged that staff were expected to follow the most recent POLST indicating DNR, but this conflicted with the active full code order and the absence of the required orange directive form.

Another resident, with a complex medical history including traumatic brain injury, hypertension, GERD, tremor, long-term anticoagulant and insulin use, schizoaffective disorder, Guillain-Barré syndrome, generalized anxiety disorder, bipolar disorder, dementia with behavioral disturbance, neoplasm, protein-calorie malnutrition, dyspnea, and type 2 diabetes with polyneuropathy, had an order indicating DNR and no feeding tube. An Advance Directive Statement Form documented that this resident did not want CPR or defibrillation in the event of cardiac arrest, did not want a feeding tube, did want IV hydration, wanted adequate pain medication even if it risked depressing respiration, wanted transfer to the hospital if their condition became terminal or irreversible, and would accept blood transfusions but not mechanical ventilation. However, the resident’s care plan initially contained no focus or interventions related to advance directives after admission, and only later was revised to state that the resident had an advance directive for CPR, do not shock, and DNI. A POLST completed later documented “Yes, CPR, attempt resuscitation” and stated that no advance directive existed, directly conflicting with the previously completed Advance Directive Statement Form.

Staff interviews further demonstrated inconsistent understanding and implementation of the facility’s advance directive process. Nursing staff reported that code status information should be available in the electronic chart and in a code status book at each nursing station, and that changes in code status should be reflected in both locations. One LPN stated that if an advance directive was incorrect, staff could go against the resident’s wishes, and a CNA reported that if forms and lists did not match the health record, they would proceed with full code until the correct status was confirmed, even though this could result in care against the resident’s wishes. The ADON and DON described a process requiring both a correctly completed POLST and a prehospital medical care directive on orange paper for DNR/DNI status, in accordance with state law and facility policy, and acknowledged that incomplete, conflicting, or inaccessible documents could lead to treatment being performed against a resident’s wishes. The facility’s own policy required review and updating of advance directives at admission, quarterly, and with changes in condition, and required social services to ensure copies were in the medical record with corresponding physician orders, but these expectations were not met for the residents reviewed.

Additional findings showed that for another resident, staff could not locate any advance directive or POLST in the electronic record or nursing station binder, despite an active order indicating DNI and do not shock status. The DON confirmed that, given this active order, both a POLST and an orange prehospital medical care directive should have been completed and present in the record, but they were not. The state prehospital medical care directive requirements specified that the DNR document must be on orange paper, signed by the patient, health care provider, and a witness or notary, and displayed visibly for first responders, yet such a valid document was not consistently available for the residents in question. Overall, the facility did not follow its own policy and state requirements to ensure that advance directives and related medical orders were accurately completed, consistently documented, and readily accessible, leading to conflicting and incomplete information regarding residents’ code status and treatment preferences.