Inconsistent Documentation of DNR Status and Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and consistent documentation of a resident’s code status and advance directives across the medical record and unit reference materials. A cognitively intact resident, as evidenced by a BIMS score of 14 on the admission MDS, had multiple serious diagnoses including hypertension, osteomyelitis, anemia, MRSA infection, rheumatoid arthritis, chronic kidney disease, type 2 diabetes with neuropathy, muscle wasting, muscle weakness, and gait abnormalities. The resident signed a Prehospital Medical Care Directive indicating refusal of all resuscitation measures in the event of cardiac or respiratory arrest, including chest compressions, intubation, artificial ventilation, defibrillation, ACLS drugs, and related emergency procedures. Despite this signed directive, the electronic health record (EHR) landing page listed the resident as a full code, and there was no corresponding DNR physician order in the orders section. A practitioner progress note documented the resident’s code status as DNR on the same date as the directive, but this was not translated into an active order. The care plan further reflected a full-code CPR focus, with a goal that CPR be initiated and followed, and interventions referencing ensuring proper documents were signed and counseling the resident and family, thereby conflicting with the signed DNR directive and practitioner note. On the unit, the Advanced Directives Book contained the resident’s orange DNR form, but the cover sheet listing resident names identified the resident as a full code, creating additional inconsistency. During interviews, an RN stated she would rely on the Advanced Directives Book to determine code status during an emergency and confirmed the discrepancy between the book’s cover sheet and the DNR form, as well as the EHR landing page showing full code. The interim DON confirmed that the EHR landing page pulls from physician orders, acknowledged there was no DNR order and no care plan reflecting DNR status, and stated that documentation needs to match so everyone is on the same page. A CNA also stated that advanced directives are documented in the EHR and in a binder for DNR residents and emphasized that all documentation must be accurate so staff know how to act. Facility policies on Advanced Directives and Physician Orders required honoring residents’ directives and ensuring orders are complete and accurate, but these expectations were not met for this resident.
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