Advance Directive and Code Status Not Properly Documented: A resident's chart lacked a current advance directive addressing code status, and no physician order was present. Although a living will was scanned into the EMR, it did not address resuscitation wishes. Staff relied on a posted sheet, chart stickers, and a CNA care plan book, but the resident's records contained conflicting code status information, including DNR/DNI on the unit sheet and Full Code on a chart form, which the DPCS acknowledged.
Two residents had inconsistent code status documentation across the EMR banner, signed forms, and pocket care plans. One resident’s signed form indicated DNR while the EMR and care plan listed Full Code, and another resident’s signed form indicated DNR while the EMR banner and physician order listed DNR with OK to intubate and the care plan listed Full Code. Staff, including a CNA/CMA, LPN, DON, and the administrator, confirmed the discrepancies and noted the risk that the residents’ wishes may not be followed in an emergency.
The facility failed to determine and accurately document code status wishes for multiple residents at admission. Several residents had no EMR documentation of their preferences, and one resident with severely impaired cognition had conflicting CPR and DNR entries in the chart, with no documentation showing the resident wished to receive CPR. Interviews confirmed the facility did not use a signed form to record code status wishes and relied on standing orders, hospital discharge information, or verbal statements documented in progress notes.
Advance directives were not maintained in the medical records for five sampled residents. Although admission paperwork and progress notes indicated that advance directive information had been reviewed for some residents, the actual documents or code status documentation were absent from the chart, and one resident’s baseline care plan did not address advance directives. The IDON stated the facility relied on baseline care plans to document residents’ wishes, but several were unavailable or stored offsite, leaving staff unable to confirm code status from the record.
A resident with severely impaired cognition had conflicting advance directive and code status documentation: the EMR banner, care plan, physician order, hall cheat sheet, and room icon all indicated DNR, while the signed advance directive stated CPR/full resuscitative measures. The SSD acknowledged the mismatch had existed for over four years, and staff used the DNR status in daily references.
Advance directive code status was not accurately reflected in the records for two residents. One resident’s chart and room signage showed full code even though a living will in the chart indicated DNR and the resident had hospice and DNR/DNI orders; another resident’s chart contained a discharged resident’s CPR directive, while the correct document elsewhere in the chart showed DNR. RN and DON interviews confirmed the records could have led to CPR being performed contrary to the residents’ wishes.
Advance directive and code status documentation was not consistently completed or available for several residents. Five residents’ PCPs were not involved in the advance directive process at the time the forms were signed, and the EMR contained mismatches between the dashboard, care plan, and scanned code status documents. For one resident, the dashboard showed DNR while the care plan still said full code, and staff reported they relied on the dashboard but could not access the Document Manager where the most current forms were stored.
Advance Directive and Code Status Not Honored: A resident with an intact BIMS score and a living will stating she did not want life-prolonging treatment was admitted as full code. Staff entered the full code order, placed a red dot on the door name plate, and documented the code status in the care plan, but there was no documentation that her wishes were reviewed with her on admission. Interviews showed staff expected code status to be discussed with the resident and/or family, yet the resident said no one had talked to her about it and she was upset that CPR was ordered.
Code Status Not Accurately Documented in EMR: The facility failed to ensure that residents' code status was current and accurately reflected in the EMR for three residents. One resident stated he wanted DNR status, but his banner, physician orders, admission note, and EMR did not consistently document it. Another resident had conflicting full code and DNR documentation with a delay between the representative's DNR form and the physician's signature. A third resident's EMR banner showed DNR despite hospital paperwork showing full resuscitation, and no signed document confirming the code status was found.
A resident with intact cognition had conflicting documentation of advance directives and code status: the EMR banner and physician order indicated DNR, while the scanned advance directive showed the resident wanted CPR. The resident confirmed she wanted CPR, and staff interviews showed the LPN would follow the physician order if records conflicted; the DON acknowledged the physician should have been contacted and the EMR updated.
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