Failure to Implement and Communicate Resident DNR/DNI and MOLST on Admission
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s advance directives and properly address code status upon admission. The facility’s own Advance Directives policy required the Social Services Director or designee, prior to or upon admission, to inquire about any written advance directives, communicate the resident’s wishes to direct care staff and the physician, and place advance directive documents in a prominent, accessible location in the medical record. The Orders for Life Sustaining Treatment policy required the admitting nurse to determine whether a MOLST form existed, notify the physician if the patient wished to discuss MOLST, and for the Social Worker to provide advance directive information and identify any existing directives at admission. Despite these policies, the facility did not ensure that the resident’s existing DNR/DNI status and MOLST/POLST from the hospital were recognized and implemented. The resident was admitted with multiple serious diagnoses, including unspecified dementia with severe cognitive impairment, CHF, acute respiratory failure with hypoxia, dysphagia, right-sided hemiplegia/hemiparesis following CVA, pneumonia, and a right humerus fracture. The hospital discharge summary documented that the resident had completed a Massachusetts MOLST/POLST and was DNR/DNI. However, review of the facility’s physician orders for the month showed only that the resident had an invoked HCP, with no physician order indicating DNR status. Nursing progress notes contained no documentation that staff had discussed advanced directives or resuscitation preferences with the resident’s HCA. The resident’s care plan did not address advanced directives, and care conference notes, including those attended by the resident’s daughter and son, lacked any documentation that advanced directives, resuscitation status, or MOLST were reviewed or discussed. When the resident was later found unresponsive and pulseless, nurses searched the electronic medical record and physical chart but could not locate a DNR order or MOLST form. In the absence of such documentation, a Code Blue was paged and CPR was initiated and continued until EMS arrived and transported the resident to the hospital, where the resident expired. In interviews, the physician stated the resident had been DNR/DNI at the hospital and should have been DNR/DNI at the facility, and that she had not been notified that the resident lacked a MOLST and was considered full code. The Director of Social Services indicated the admitting social worker should have reviewed and documented the resident’s advanced directives and MOLST during admission and care conferences, and the DON stated the admitting nurse should have identified the hospital DNR order, notified the physician, and obtained a MOLST and DNR order, but this had not occurred.
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