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.
A resident's advance directive wishes were not accurately identified or documented after returning from a hospital stay, resulting in conflicting code status information between the EMR and paper chart. The EMR was updated to 'Intubate Only' without discussion with the resident, despite signed DNR documents and a care plan indicating DNR status. Staff confirmed they would follow the highest level of care listed, which did not reflect the resident's wishes.
A resident with moderate cognitive impairment had conflicting documentation regarding her CPR wishes, with her advance directive indicating DNR and a separate form in the paper chart indicating she wanted CPR. Staff referenced both the EMR and paper chart, which did not match, leading to confusion about the resident's true code status. Facility policy required honoring advance directives, but inconsistent records resulted in uncertainty.
A resident's right to refuse a COVID-19 vaccination was not honored when an LPN misread a declination form and administered the vaccine despite the resident's verbal refusal. The resident expressed frustration over the lack of autonomy in decision-making. The incident was reported, and the resident's power of attorney was informed and accepted the situation. No further concerns were identified among other residents and staff.
A resident with severe cognitive impairment did not have proper documentation of a power of attorney for healthcare, leading to unauthorized release of medical information to a friend. The friend, listed as an emergency contact, gave verbal consent for treatments and was informed about medication changes without formal authorization. Staff interviews revealed a lack of awareness about the need for proper documentation, potentially violating HIPAA regulations.
A facility failed to maintain a physician's order consistent with a resident's advance directive. The resident's EMR showed a DNR status, but a full code order was in place. The DON and MDS nurse were aware of the issue, but no updated order was obtained from the physician. The facility's policy requires specific and updated orders for life-sustaining measures.
The provider failed to update a resident's code status from full code to DNR in their medical records, despite a care conference note and an Expression of Healthcare Preferences form indicating the change. The administrator admitted that the necessary steps to update the physician's orders and the EMR dashboard were not completed.
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