F0578

D

Failure to Determine and Document Resident Advance Directives on Admission

Wauconda, Illinois Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to determine and document a resident’s advance directives upon admission, as required by facility policy. The resident was admitted with diagnoses including metabolic encephalopathy, urinary tract infection, and Type 2 Diabetes Mellitus, and was documented as alert and oriented to person, place, time, and situation, though forgetful. The face sheet section for advance directives was left blank, and admission nursing documentation did not mention any discussion of advance directives with the resident or family. The resident’s son-in-law reported that the resident arrived from the hospital with a DNR wristband in place, which the admitting nurse removed, and that no staff asked him or his wife about the resident’s wishes regarding advance directives, despite the hospital indicating that advance directive forms would be sent with the resident.

Subsequently, when the resident was found unresponsive with no respirations or carotid pulse, the RN on duty checked the medical record, saw an order for full code, and initiated CPR while 911 was called. CPR continued until EMS arrived, and a pulse was eventually regained before transfer to the hospital. Staff interviews, including with the RN who performed CPR, another RN present that morning, the DON, the ADON, and the admitting RN, confirmed that facility protocol requires that advance directives be determined and documented at admission, but the admitting RN did not recall whether this was done for this resident. The hospital discharge summary in the facility record listed the resident’s code status as DNR, while the facility’s physician order sheet contained an order for full code, demonstrating that the resident’s actual wishes regarding code status were not properly identified and documented at admission.