Inconsistent Documentation of Advance Directives and Code Status
Penalty
Summary
The facility failed to ensure that a resident’s advance directives were consistent and correctly documented throughout the clinical record. The resident, who had diagnoses including COPD, atrial fibrillation, and vascular dementia, was admitted to hospice and had a Prehospital Medical Care directive signed by the resident’s representative indicating a DNR (Do Not Resuscitate) status. However, an advance directive form signed by the resident several days later in the clinical record had no selection marked for either Full Code or DNR. There was no evidence that the resident’s code status was reflected in the care plan or in physician’s orders. During interviews, the Clinical Resource staff member acknowledged that the advance directive on file was not adequate because the resident’s choice was unclear on the signed form, which could cause confusion about the resident’s wishes. An RN explained that in an emergent code situation, staff would check the electronic chart banner and then the hard chart at the nurse’s station; for this resident, the electronic banner indicated DNR, while the signed form in the hard chart showed no code status selection, which the RN interpreted by default as Full Code. The RN noted that a signed DNR could be found elsewhere in the hard chart, but the lack of consistency across the resident’s clinical record could lead to confusion about which directive to follow. The facility’s policy stated that changes or revocations of advance directives must be in writing to the administrator, reflected in the MDS and care plan, and that the DON or designee would notify the attending physician so appropriate orders could be entered, but this was not consistently carried out for this resident.
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