A resident with dementia, reduced mobility, and type 2 DM was admitted without any documented advance directive, POLST, or physician order for life-sustaining treatment in the medical record. The MDS showed the resident was cognitively impaired. During interviews, the resident’s POA reported they had not selected or signed a POLST, and the Regional Nurse Consultant confirmed there were no life-sustaining treatment orders or POLST on file, indicating the facility failed to ensure the resident’s right to formulate and document advance directives.
A resident with severe cognitive impairment, multiple complex medical conditions, and a POLST directing provision of artificial nutrition and hydration via surgically placed tubes was care planned as NPO with enteral feeding for all nutrition needs, yet had no active tube feeding orders and was observed on multiple occasions without any feeding infusing. An RN reported that hospice had discontinued the feeding, the POA stated she had been told feeding could not be restarted despite wanting it continued, and the DON was unaware the feeding had been stopped. The MD acknowledged hospice stopped the feeding due to aspiration risk and stated that the POLST should be revised if G-tube feeding is discontinued, while facility policy affirms residents’ rights to determine life-sustaining treatments, including artificial hydration and nutrition.
A resident admitted with metabolic encephalopathy, UTI, and Type 2 DM was documented as alert and oriented, but the advance directive section of the face sheet was left blank and no admission notes reflected any discussion of code status with the resident or family. The resident arrived from the hospital wearing a DNR wristband, which the admitting RN removed, and the family reported that no staff asked about the resident’s wishes despite the hospital indicating that advance directive forms would be sent. Later, when the resident was found unresponsive, an RN checked the chart, saw a full code order, and initiated CPR until EMS arrived and a pulse was regained. Staff interviews confirmed that facility protocol requires determining and documenting advance directives at admission, yet the admitting RN did not recall doing so, and the facility record contained a hospital discharge summary listing DNR status alongside a physician order for full code.
A resident with multiple chronic conditions had a physician order and POLST indicating DNR/No CPR, but the EMR banner listed the resident as “Full Code,” and the POLST was not timely scanned into the record. After the resident fell, an RN informed EMS that the resident was a full code based on the EMR banner, and EMS initiated full resuscitative efforts when the resident became pulseless. The DON and wound care nurse reported that residents are treated as full code until paperwork is received and that the admitting nurse would not have entered a DNR order without having the POLST, indicating the facility possessed the DNR documentation but failed to update the EMR banner, resulting in resuscitation contrary to the resident’s advance directive.
Advance directive orders were not documented in the physician orders for a resident with a DNR. Social Services and the DON described admission processes for identifying and recording advance directives, but the resident’s record showed a DNR on the social services assessment while the face sheet, care plan, and POS lacked the required code status order.
A resident was admitted from a hospital with discharge orders and a POLST indicating DNR status, and a POA document identified a healthcare representative. Despite this, a physician order listed the resident as Full Code, and the admission care plan omitted any reference to advance directives. The POA reported being told that the facility could not honor the POLST until the medical director signed it, even though the DON later confirmed that a physician-signed POLST should be honored without additional signatures. The facility’s policy requiring advance directives to be copied, charted, and communicated on admission was not followed, resulting in the resident’s DNR wishes not being implemented.
A resident with multiple serious cardiac and renal diagnoses had conflicting information regarding code status across the EMR, orders, and care plan. The face sheet, EMR dashboard, and active physician orders all listed the resident as No CPR/DNAR, but the active care plan documented that the resident had not chosen any advance directives and was full code. No signed POLST or advance directive documents were uploaded in the EMR or available in the designated black folder at the nursing station, despite facility policy requiring this for residents with DNR status. A nurse reported she would follow the DNR order and withhold emergency interventions, while the resident, who was alert and decision-capable, stated he wanted to be resuscitated and confirmed he wished to be full code, demonstrating a failure to align documentation and orders with the resident’s expressed treatment preferences.
The facility failed to accurately reflect and document advance directives and code status for two residents. For one resident, physician orders and a POLST form identified a DNR/DNAR status, but the comprehensive care plan continued to list the resident as full code with directions to perform CPR and provide intubation and mechanical ventilation. For another resident, no code status was documented on the face sheet or in active physician orders, despite the DON’s statement that code status must be recorded in two locations in the EMR. These lapses occurred despite facility policies requiring comprehensive, person-centered care plans and specific physician orders addressing each advance directive.
The facility failed to ensure that multiple residents’ POLST orders for scope of treatment were accurately reflected in their EMR face sheets, physician order sheets, and care plans. For several residents, documentation listed only DNR status, while their signed POLST forms included additional directives such as selective or limited additional interventions, use of CPAP/BiPAP, IV fluids, antibiotics, vasopressors, antiarrhythmics, cardiac monitoring, hospital transfer parameters, and a time-limited trial of tube feeding. These detailed treatment preferences were not incorporated into the care plans or EMR, even though an LPN reported relying on the EMR status board to determine code status in emergencies, and facility leadership acknowledged that POLST instructions should match and be reflected in the medical record and care plans.
A resident with multiple serious diagnoses and cognitive impairment had a care plan and POLST indicating full code/CPR status, but no corresponding code status order was entered on the physician order sheet in the EMR. The DON reported that admitting nurses are expected to implement code status orders from verified hospital transfer and admission orders so that staff know and can honor the resident’s wishes. Facility policies on advance directives and resident rights require determining and documenting code status upon admission, yet this resident’s code status was not converted into an active physician order.
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