Inconsistent Advance Directive Documentation and Orders for a Resident
Penalty
Summary
The facility failed to ensure that one resident’s advance directive documentation, physician order, and care plan were consistent and accurately reflected the resident’s treatment wishes in the event of a medical emergency. The resident was admitted with multiple significant diagnoses, including acute kidney failure, acute on chronic diastolic congestive heart failure, and ventricular premature depolarization. The face sheet, EMR dashboard, and active order summary all indicated a No CPR/Do Not Attempt Resuscitation (DNAR) status. However, the active care plan stated that the resident had not chosen any advance directives due to personal preference and identified the resident’s code status as full code. Review of the EMR revealed no uploaded advance directive forms or signed POLST to support the DNR order. During interviews, the Social Service Director (SSD) confirmed that, according to facility policy, signed POLST and/or advance directive documents for residents with DNR status should be uploaded into the EMR and an actual signed copy should be kept in a black folder at the nursing station. The SSD found that neither an uploaded document nor a physical copy was available for this resident. A registered nurse, when asked about the resident’s code status, stated she would rely on the EMR dashboard and active orders, which showed DNR, and that no emergency action would be taken if the resident were found unresponsive. The nurse also confirmed there were no supporting advance directive documents in the EMR or black folder and acknowledged the contradiction between the DNR order and the full code care plan. When the SSD directly asked the resident, who was alert and able to make decisions, the resident stated he wanted to be resuscitated and confirmed he wished to be full code, further demonstrating the inconsistency between the resident’s expressed wishes, the orders, and the care plan, contrary to the facility’s advance directive policy and procedure.
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