Advance directive and code status documentation were not properly executed for a resident with dementia, subdural hemorrhage, subarachnoid hemorrhage, and anxiety who was documented as cognitively intact. The EMR showed a DNR form signed by the resident’s family member witness, even though there was no incompetency determination and the SSD and DON both confirmed the witness should not have signed the form.
Advance Directive Not Accurately Reflected in Medical Record: A resident with cerebral infarction and vascular dementia had a legal guardian who signed DNR/no resuscitation documents, but the Order Summary and EMAR banner still showed Full Resuscitation. The DON confirmed the EMAR was inaccurate and stated the Unit Manager was responsible for ensuring advance directive forms were completed and the EMAR matched the resident's or guardian's wishes.
The facility failed to timely respond to changes in condition for two residents, including one with severe cognitive impairment and another with dementia, CHF, diabetes, and a history of UTIs. Family members and DPOAs reported concerns about confusion, agitation, pain, SOB, and other worsening symptoms, but hospital evaluation was delayed while staff waited for physician input. Both residents were later admitted to the hospital with serious infections and other acute conditions, including sepsis, pneumonia, and respiratory failure.
The facility failed to ensure two witness signatures were obtained when a Responsible Party signed a DNR form for a resident with severe cognitive impairment, dementia, and a guardian in place. The DNR showed the RP signature first, followed by the MD signature and then the two witness signatures, and an SSA stated the process required two witnesses to observe the signing by the resident or RP.
A resident with multiple chronic conditions and intact cognition had an Advance Directive form marked as if they chose to formulate directives, but no Advance Directive documentation was in the EMR and the resident said staff had not offered help setting one up. Another resident with dementia and other serious diagnoses had a code status form signed despite records showing the resident had been declared incompetent by both a physician and a psychologist, and staff stated they were told the resident had to sign on admission.
A resident’s advance directive paperwork was not thoroughly completed. The DNR form was missing dates for the resident signature and one witness signature, and there was no active physician order reflecting DNR status. The DON confirmed the missing dates and the absence of an active code status order.
A resident with diagnoses including borderline personality disorder, mild intellectual disabilities, opioid dependence, PTSD, and dialysis dependence was found to be not capable of making medical treatment decisions, yet the resident still signed an AD form that was witnessed by two staff. No DPOA or legal guardian was documented in the EMR, and the form section for a resident without decision-making capacity and without legal representation was not used.
Advance directive status was not established, documented, or reviewed for a resident with intact cognition and a stroke history. The resident said he did not recall anyone discussing advance directives, and the EMR had no advance directive, no evidence of admission screening or education, and no care plan entry addressing his preferences. A progress note later cited by the DON was amended after the surveyor requested documentation, and the SW acknowledged the original note did not include advance directive information.
A resident with CHF, cardiomyopathy, diabetes, and cognitive communication deficit had an advance directive requesting no CPR, but the EMR listed the resident as Full Code. When the resident was found unresponsive with no HR or respirations, staff initiated chest compressions, transferred the resident to the floor, and continued CPR until the DNR paperwork was located and CPR was stopped.
Advance directives were not properly formulated for two residents. One resident with severe cognitive impairment had a DNR order signed by a financial DPOA, but the chart did not contain a medical DPOA, a DNR care plan, or documentation that the legal representative was asked for medical decision-making authority. Another resident with dementia and a court-appointed guardian was listed as Full Code in the EMR without evidence that the guardian established code status or that the advance directive was addressed in social service notes.
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