Failure to Honor Advance Directives and Timely Initiate CPR
Summary
The facility failed to ensure that a resident's advance directives were implemented in a timely manner and did not honor the resident's wishes regarding full code status. A resident with multiple serious diagnoses, including metabolic encephalopathy, multiple sclerosis, sepsis, dysphagia, acute respiratory failure with hypoxia, diabetes type 2, pneumonia, acute kidney failure, myocardial infarct, and hypertension, was documented as cognitively intact and had an active order for full code status. Despite this, when the resident's oxygen saturation dropped to 84% with supplemental oxygen, the LPN on duty did not notify the medical provider or document any interventions regarding this significant change in condition. Later, the resident was found pulseless and not breathing. There was confusion among staff regarding the resident's code status, as conflicting information was found between the hospital transfer form, which indicated DNR, and the facility's electronic health record, which indicated full code. Staff delayed initiating CPR for approximately 45-60 minutes while attempting to clarify the resident's code status, contacting administration, hospice, and the medical team instead of following the full code order present in the record. During this time, no resuscitative efforts were made, and the resident was ultimately pronounced dead. Interviews with staff revealed a lack of clarity and understanding regarding the process for verifying and acting on code status, as well as inconsistent documentation and communication. The facility's policy required that any changes to advance directives be properly documented and communicated, but this was not followed. The failure to promptly initiate CPR in accordance with the resident's documented wishes and physician orders resulted in the resident's wishes not being honored.
Removal Plan
- An audit of each resident's code status was completed.
- The licensed nurse was suspended, pending the facility's investigation.
- A Quality Improvement Performance Committee was conducted to review the recommendations from the root cause analysis.
- A performance improvement plan was developed and initiated based on root cause analysis as determined by the QAPI committee.
- Code blue drills were initiated on multiple shifts, with ongoing drills to continue until all staff have completed and with the results reported to the QAPI committee.
- The regional director of social services provided education to licensed nurses and the interdisciplinary team on advanced directives including identification of a valid DNR and who can initiate a DNR, with a posttest upon completion.
- Licensed nurses and CNAs received education on the CPR policy and procedure including responding to a code blue and the roles/responsibilities during a code.
- Staff received education related to the abuse, neglect, exploitation, and misappropriation policy.
- Licensed nurses received education on the identification of a change in condition including competency.
- Newly hired licensed nurses will receive education upon hire, or accepting a shift, to include the CPR policy/procedure, advanced directives policy/procedure, identification of change in condition with competency, abuse/neglect/exploitation/misappropriation, and participation in code blue drills.
- Ongoing training is being conducted for the identification of change in condition with competency.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia/TBI and fluctuating cognition repeatedly told staff she wanted to go home with a family member, but the facility relied on an invalid MPOA/Responsible Party arrangement. The chart did not contain a valid resident-signed MPOA notarized for the named agent, and staff interviews showed they knew the resident could express her wishes yet did not document action to honor her discharge preference.
Incomplete DNR Documentation: The facility failed to ensure DNR forms were completed correctly for three residents. One resident's DNR lacked required physician and resident signature details, another was missing a witness signature, and a third was missing a dated physician signature. The SW and ADM stated the forms were not valid if not filled out correctly and that there was no system for monitoring DNR accuracy.
A resident with CAD, major depressive disorder, and dementia had documentation in the care plan indicating the presence of a living will and DPOAHC, but only a single, untitled page in the hard copy chart referenced these documents without listing the location of the living will or the name of the DPOAHC. The form simply indicated that the resident had a living will and DPOAHC, leaving key fields blank. The DON stated this was the only documentation available and reported that the resident’s POA refused to provide a copy of the living will, yet no documentation of this refusal was found. The DON confirmed that no copy of the resident’s advance directives was maintained in the medical record.
The facility failed to adequately inform and assist multiple residents with Advance Health Care Directives (AHCDs). One resident requested an AHCD form but received no documented follow-up or assistance, and this issue was not addressed in later interdisciplinary team meetings. Another resident had a Five Wishes AHCD document on file that lacked required witness signatures, despite clear instructions that witnessing was necessary for validity. A third resident initially declined an AHCD, but the facility did not periodically revisit the discussion, and the resident later reported that no one had discussed AHCDs with him and expressed a desire to complete one.
A resident with orthopedic aftercare and muscle weakness had expressed a wish to be DNR, which was documented in a social worker note but not entered as a physician order or care plan, and no POLST was present in the paper chart. Facility policy requires resident treatment choices to be incorporated into the medical record and orders, but staff could not locate any code status in the electronic or paper record. In interviews, an RN and an LPN stated they would treat the resident as a full code and start CPR if code status could not be found, while the DON acknowledged the DNR order was missed in batch orders and not transcribed into the electronic chart.
The facility failed to verify and implement resident advance directives and DNR status at admission, resulting in conflicting documentation and treatment that did not align with residents’ expressed wishes. One resident with hospital records and a portal summary clearly indicating DNR status was admitted without an admission packet, listed as full code in the EMR and care plan, and received CPR after being found unresponsive because staff relied on the EMR banner and did not review supporting DNR documents or contact the POA to resolve discrepancies. Another resident with hospital DNR documentation and a completed OOH-DNR form was care planned as full code, and physician orders alternated between full code and DNR without timely clarification or documentation of discussions with the responsible party. Interviews with the DON, social worker, admissions coordinator, marketer, NP, and medical director showed that no single role was clearly accountable for reconciling advance directives at admission, the DON did not review clinicals, the social worker only verified code status at the 72-hour care plan, and the admission packet containing advance directive acknowledgements was not consistently provided or reviewed with responsible parties, leading to systemic failures in honoring residents’ code status.
Invalid MPOA and Unaddressed Resident Discharge Wishes
Penalty
Summary
The facility failed to ensure Resident #40’s right to formulate an advance directive and failed to verify that Family Member B had valid authority to act as Responsible Party. Resident #40 was admitted with diagnoses including traumatic subdural hemorrhage with loss of consciousness and Alzheimer’s disease with late onset. Her records also reflected severe cognitive impairment on a quarterly MDS, but multiple notes documented that she could express her needs and wants, was oriented at times, and told staff she wanted to go home with Family Member D. The admission agreement listed Family Member B as Responsible Party and indicated medical decisions, admission, care, and discharge decisions were authorized, but the record did not contain a valid MPOA signed by Resident #40 and acknowledged before a notary public. The MPOA in the chart showed the signature acknowledged before a notary was Family Member B’s, not Resident #40’s. The record also did not show physician certification that Resident #40 lacked competence to make health care decisions, and did not show documentation that Resident #40 authorized Family Member B as her legal guardian or agent. During the stay, staff documented that Resident #40 repeatedly stated she wanted to discharge home with Family Member D and that she did not like being at the facility. Interviews with CNA, Social Services, Activities, LVN, ADON, MDS Coordinator, DON, BOM, and the Administrator confirmed that staff were aware of her wishes and that she could verbalize them. The Administrator note described a dispute between Family Member B and Family Member D regarding discharge, law enforcement involvement, and discharge home with Family Member D at Resident #40’s request. The record did not show that Social Services, nursing leadership, or the Administrator took documented action to honor her discharge wishes after learning of them.
Incomplete DNR Documentation
Penalty
Summary
The facility failed to ensure that advance directive and DNR documentation was completed accurately for 3 of 6 residents reviewed for advance directives. Resident #1 had a DNR order on the face sheet, physician order summary, and care plan, but the DNR form was incomplete because the resident's signature was not dated, the physician did not print his name after signing, the physician's signature was not dated, and the physician's license number was missing. Resident #5 also had DNR status documented on the face sheet, physician order summary, and care plan, but the DNR form was missing a witness signature. Resident #6 had DNR status documented on the face sheet, physician order summary, and care plan, but the DNR form was missing the physician's dated signature. During interviews, the SW and ADM stated the DNRs were not valid if not filled out correctly and verified the missing information for Residents #1, #5, and #6. They stated there was no system for monitoring DNRs for accuracy, and the ADM identified human error as the reason the forms were incomplete.
Failure to Maintain Complete Advance Directive Documentation in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a copy of a resident’s advance directive in the medical record as required by the State Operations Manual (SOM). The SOM defines an advance directive as a written instruction such as a living will or durable power of attorney for health care (DPOAHC), and clarifies that a POLST is not an advance directive. The resident involved was admitted with multiple diagnoses including coronary artery disease, major depressive disorder, and dementia. The resident’s care plan, revised on 1/27/26, documented that there was one page of a living will and DPOAHC in the chart. On review of the hard copy chart, surveyors found only a single, untitled page dated 2/6/25 that referenced the existence of a living will and DPOAHC but did not identify the location of the living will or the name of the DPOAHC. The form indicated “yes” to the resident having a living will and DPOAHC, but the lines for the location of the living will and the name of the person holding the DPOAHC were left blank. When questioned, the DON stated that this was all the documentation the facility had and reported that the resident’s POA had refused to bring in a copy of the living will. When surveyors requested documentation of this refusal, none was provided. The DON confirmed that the facility did not have a copy of the resident’s advance directives.
Failure to Inform and Assist Residents With Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to properly inform and assist residents with formulating Advance Health Care Directives (AHCDs) and to ensure that existing AHCD documents were validly executed. For one resident (R17), the EHR showed that AHCD information was discussed and the resident requested a blank AHCD form on 04/14/25. However, there was no subsequent documentation that the resident completed an AHCD or that the facility provided follow-up assistance after that date. The Social Services Assistant (SSA) confirmed there was no follow-up documentation, and the most recent interdisciplinary team meeting record for this resident contained no reference to AHCD follow-up. For another resident (R170), the facility obtained a completed Five Wishes document intended to serve as an AHCD, but the document lacked required witness signatures, despite instructions on the form stating it must be signed and witnessed as directed to be legal and valid. The SSA confirmed the absence of witness signatures. For a third resident (R153), the EHR showed that AHCD information was last discussed on 12/10/24, at which time the resident declined to formulate an AHCD. There was no evidence that the facility revisited the discussion or reoffered assistance after that date. In a subsequent interview, this resident reported that the facility had not discussed an AHCD with him and stated he would like to complete one.
Failure to Document and Communicate Resident DNR Code Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to formulate and have an advance directive and code status accurately reflected and readily available in the medical record. Facility policy on advance care planning states that residents’ choices about treatment, including decisions to decline treatment, are to be incorporated into the medical record and related orders. Resident 39’s record showed diagnoses including a right artificial knee joint, encounter for orthopedic aftercare, and muscle weakness. However, review of the resident’s clinical record did not show any physician order or care plan documenting her code status. Review of the resident’s paper chart also failed to reveal a POLST form. During interviews, an RN and an LPN both stated that if they could not locate a resident’s code status in the electronic or paper record, they would treat the resident as a full code and initiate CPR. The resident reported that advance directive information had been reviewed with her at admission and that her wish was to be DNR. The clinical record contained a social worker note documenting that the resident declined to complete a POLST but requested DNR code status. The DON later explained that the DNR code status order for this resident had been missed from the batch physician orders and was not transcribed into the electronic chart, resulting in the absence of an electronic order that nursing staff could locate in an emergency.
Plan Of Correction
1. Order for resident #39 transcribed and placed in electronic medical record. 2. Advanced Directive orders audited for current residents to ensure electronic records reflect POLST/Advanced Directive. 3. Educate licensed nursing staff on the process of transcribing POLST/Advance Directive's at time of admission. 4. Audit all new admission X1 month for transcription of POLST/Advance Directive orders correctly listed on electronic chart, then 5 random admissions X2 months. All audits will be brought to QAPI for further recommendations for quality assurance and performance improvement.
Failure to Verify and Implement Resident Advance Directives and DNR Status at Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ advance directives were accurately identified, clarified, and implemented upon admission, resulting in discrepancies between documented code status and residents’ expressed wishes. For one resident (CR#1), hospital records and the admission portal summary clearly indicated a DNR status and receipt of a living will, yet the facility’s baseline care plan and EMR listed her as full code. Her advance directives section in the facility record was blank, and there was no admission packet or agreement on file. Physician orders initially documented her as full code, and although a physician progress note later reflected both “Full code” and “Advance Directives DNR,” no clear, timely clarification was obtained. Staff did not review the miscellaneous tab in the EMR for DNR paperwork, and no one contacted the POA to reconcile conflicting documentation. On the morning of the event, CR#1 was found unresponsive with no palpable pulse. Nursing staff confirmed her status as full code using the EMR banner and initiated CPR, which continued until EMS arrival and transport to the hospital. EMS continued resuscitative efforts, including intubation and mechanical CPR, until the POA notified hospital staff that the resident’s wishes were DNR, at which point resuscitation was stopped and the resident was pronounced deceased. Interviews with family and the hospital case manager confirmed that the resident had chosen DNR status during her hospital stay and that DNR documentation had been sent to the facility prior to admission. The facility did not clarify the discrepancy between hospital DNR documentation and internal full-code orders before the change in condition occurred. For another resident (Resident #1), hospital nephrology notes and the hospital transfer cover page documented a DNR code status, and an OOH-DNR form had been completed, signed by the legal guardian, witnessed, and notarized. However, the facility’s care plan identified this resident as full code, and physician orders alternated between full code and DNR on multiple dates, with changes verified only by medical record review and without documented prior clarification. The medical director’s signature on the OOH-DNR form was delayed, and there was no documentation addressing the resident’s advance directives prior to a late social worker note confirming the RP’s wish for the resident to remain DNR. Interviews with the DON, social worker, admissions coordinator, marketer, NP, and medical director revealed that no specific staff member was clearly responsible for verifying and reconciling advance directives at admission, that the DON did not review clinicals before or after admission, and that the admissions coordinator did not provide or review the admission packet containing advance directive acknowledgements with CR#1’s POA. These systemic gaps led to residents being treated as full code despite prior DNR designations and without timely clarification of discrepancies in their advance directive documentation. The facility’s own staff acknowledged that the admission process for advance directives was fragmented and that responsibilities were unclear. The DON stated there was no specific staff responsible for ensuring residents’ wishes and code status were accurately entered at admission and that she did not investigate CR#1’s code status concerns or audit advance directives after the incident. The social worker confirmed she only verified code status at the 72-hour care plan and did not review admission documentation or contact CR#1’s POA before the resident’s death. The admissions coordinator admitted she did not send an admission packet to CR#1’s POA, did not review its contents with responsible parties, and did not recognize that the packet contained advance directive acknowledgements. The administrator and medical director both described failures in communication, documentation, and timely clarification of discrepancies, and the facility later identified additional residents whose DNR status could not be confirmed and whose code status had been changed to full code while verification was pending.
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