Failure to Maintain Complete Advance Directive Documentation in Medical Record
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with multiple chronic conditions had a physician order indicating DNRCC status, but no signed DNR/DNRCC form was present in the chart for more than a month after admission. When the resident was sent to the hospital by EMS, an RN informed EMS of the DNRCC status and provided a face sheet reflecting this, but could not supply the required state DNR form signed by a physician. EMS staff confirmed they did not receive the necessary documentation and therefore treated the resident as full code during transport, contrary to the facility’s own advanced directives policy that requires providing EMS with a copy of the resident’s advance directive.
A resident with multiple serious diagnoses had a care plan and physician orders reflecting a DNRCCA code status, but the signed advance directive was never scanned into the electronic record as required. Although the transfer form listed the resident as DNRCCA, there was no signed code status form available in the electronic system, and an LPN could not locate the paperwork when sending the resident to the ED. The DON confirmed the DNRCCA document was not scanned into PCC, contrary to facility policy requiring advance directives to be maintained in a consistent, readily retrievable section of the medical record.
Inaccurate advance directive documentation was found for four residents. Records showed mismatches between physician code status orders, care plans, face sheets, and hard-chart documents, including DNRCC orders that were not reflected consistently and full-code listings that conflicted with DNRCC documentation. Staff confirmed several of these discrepancies during interview, and facility policy required advance directives to be reviewed and documented on designated forms and assessments.
Advance directive documentation was missing or incomplete for three residents. Two residents had DNRCC-A status documented in the chart and on physician orders, but their advance directive forms were not signed by a physician, and one resident had DNRCC-A status documented but no advance directive was present in the medical record. An LPN verified the missing and incomplete documentation.
The facility did not timely implement and enter advance directive code status orders for two residents. One resident was discharged from the hospital with a DNRCCA status, but the facility delayed initiating any code status order and then entered the resident as Full Code despite signed DNRCCA paperwork later uploaded to the EHR. Another resident with multiple chronic conditions had DNRCCA paperwork signed and uploaded, but no corresponding code status order was entered into the EHR after readmission. Staff interviews confirmed these delays and omissions occurred despite facility policy requiring nurses to obtain and enter physician orders reflecting residents' executed advance directives.
A resident with COPD, emphysema, encephalopathy, malignant neoplasm, fibromyalgia, and dementia requested a code status change from Full Code to DNRCC during a care conference, but the request was not acted on at that time. The chart remained Full Code until a later DNRCC-A form was completed, and the DON and Social Services confirmed the request was not followed up on when first made.
Failure to Provide Required DNRCC Documentation to EMS During Resident Transfer
Penalty
Summary
The deficiency involves the facility’s failure to properly implement and document a resident’s do not resuscitate comfort care (DNRCC) status and provide the required documentation to EMS during transfer. The resident was admitted with multiple diagnoses including chronic obstructive pulmonary disease, peripheral vascular disease, type 2 diabetes mellitus, and encephalopathy, and was documented as cognitively intact and needing assistance with ADLs. A physician’s order dated 03/02/26 indicated the resident’s code status as DNRCC, but review of the medical record from admission through 04/03/26 showed there was no DNR or DNRCC form signed by a physician in the chart. The medical record also did not contain a DNRCC form, despite the code status order. On 04/03/26, a nurse received an order to send the resident to the hospital via EMS and called 911; EMS transported the resident. The EMS run report documented that facility staff stated the resident’s code status was DNRCC, but they were unable to provide a DNRCC form to accompany the resident. Interviews with the RN who arranged the transfer and with two paramedics confirmed that the facility did not have a signed DNRCC form on file to give to EMS, and that only a face sheet indicating DNRCC status was provided. EMS personnel reported that, without the required state DNR form signed by a physician, they were required to treat the resident as full code during transport and upon hospital admission. Review of the facility’s Advanced Directives policy showed that the nurse supervisor was required to inform EMS of a resident’s advanced directive and provide a copy of the directive, which did not occur in this case.
Failure to Maintain Accessible DNRCCA Documentation in Medical Record
Penalty
Summary
The facility failed to ensure that a resident’s documented code status and advance directive paperwork were maintained and readily accessible in the medical record as required by policy. Former Resident #116 was admitted with serious medical conditions including sepsis due to enterococcus, acute and subacute infective endocarditis, bacteremia, urinary tract infection, and acute pulmonary edema. The resident’s care plan, initiated on 11/12/25, identified an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA), and physician orders consistently reflected a DNRCCA code status from admission through discharge. The care plan also specified that the resident’s code status would be in the medical record at all times. Despite this, review of the electronic medical record (PCC) showed that no DNRCCA advance directive document was scanned into the system from admission through discharge. The eInteract hospital transfer form completed on 01/09/26 listed the resident’s code status as DNRCCA, but there was no signed code status form on file in the electronic record. During interview, the DON stated that the DNRCCA paperwork for this resident was in medical records but acknowledged it had not been scanned into PCC, leaving nurses without electronic access to the document. In a separate interview, an LPN reported being unable to locate the DNRCCA paperwork when preparing to send the resident to the emergency department. Facility policy on Advance Directives required that copies of any executed advance directives be obtained, maintained in the same section of the medical record, and be readily retrievable by staff, which was not met in this case.
Inaccurate Advance Directive Documentation
Penalty
Summary
The facility failed to ensure current and accurate documentation of residents’ advance directives was included in the medical record for four residents reviewed. Resident #24 had diagnoses including chronic pain syndrome, major depressive disorder, and bipolar disorder, was cognitively intact, and had a physician order for DNRCC and a care plan reflecting DNRCC, but the hard chart had an undated sticker indicating full code status. Resident #65 had diagnoses including cerebral infarction, fracture of the left femur, and vascular dementia; the physician order in the EHR listed full code, while the care plan listed DNRCC and the hard chart contained a signed Ohio DNRCC form, and RN #223 confirmed the orders in the hard chart did not match the EHR. Resident #6 had diagnoses including generalized muscle weakness, COPD, and chronic pain syndrome, was cognitively intact, and had a physician order for DNRCC, but the care plan and face sheet listed full code. Resident #27 had diagnoses including traumatic brain injury, dementia, and bipolar disorder, had severe cognitive impairment, and had a physician order for DNRCC, but the face sheet listed full code. Facility policy stated advance directives were to be reviewed upon admission, readmission from the hospital, quarterly, and annually, with documentation noted on the advance directive care plan, quarterly social work assessment, and/or admission/annual advance directive information form.
Advance Directive Documentation Missing or Incomplete
Penalty
Summary
The facility failed to ensure that advance directives were present in the medical record for one resident and failed to ensure that the advance directive forms for two other residents were signed by a physician. Resident #28 had diagnoses including unspecified dementia, unspecified atrial fibrillation, and sleep apnea, and the quarterly MDS showed impaired cognition. The care plan and physician order documented a DNRCC-A status, but the advance directive form in the record was not signed and completed by a physician. Resident #97 had diagnoses including chronic kidney disease, atrial fibrillation, and intestinal obstruction, and the entry MDS showed the resident was cognitively intact but dependent on staff for toileting and ADLs. The care plan and physician order documented DNRCC-A status, but the advance directive form was not signed and completed by a physician. Resident #80 had diagnoses including acute respiratory failure with hypoxia, essential hypertension, and chronic kidney disease, and the quarterly MDS showed moderately impaired cognition with dependence for ADLs and supervision for toileting. The care plan and physician order documented DNRCC-A status, but the resident did not have an advance directive in the medical record. An LPN verified that Residents #28 and #97's advance directives were not signed by a physician and that Resident #80 did not have an advance directive present in the medical record or paper chart.
Failure to Timely Implement and Enter Advance Directive Code Status Orders
Penalty
Summary
The facility failed to ensure that residents' advance directives and code status orders were obtained and implemented timely upon admission or readmission. For one resident with diagnoses including hypertensive emergency, acute pulmonary edema, and Sjogren syndrome, the hospital discharge summary identified the resident as DNR-Comfort Care Arrest (DNRCCA) at the time of admission. However, no physician order for code status was initiated until several days later, and when it was entered, the resident was listed as Full Code. Although DNRCCA paperwork was signed by the physician and later uploaded into the electronic health record, the corresponding physician order in the record continued to reflect Full Code status. For another resident with conditions including a stage 4 pressure ulcer, paraplegia, generalized anxiety disorder, major depressive disorder, and neuromuscular bladder dysfunction, DNRCCA paperwork was signed by the physician and uploaded into the electronic medical record, but no physician order for code status was entered into the record following the resident’s readmission from a hospital stay. Interviews with the Regional Director of Clinical Services, the Vice President of Clinical Services, and the DON confirmed that code status orders were either delayed, incorrect, or missing, despite the facility’s policy requiring that, after execution of the Ohio Advance Directive form, a nurse obtain a physician order consistent with the resident’s wishes and enter that order into the electronic health record.
Advance Directive Status Not Addressed Timely
Penalty
Summary
The facility failed to ensure a resident’s advance directive status was addressed timely and accurately in the medical record. Resident #59 was admitted with diagnoses including COPD, emphysema, encephalopathy, malignant neoplasm, fibromyalgia, and dementia. The resident’s physician orders showed Full Code status from admission through 02/10/26, and the quarterly MDS completed on 11/12/25 indicated the resident was cognitively intact. During the care conference on 12/04/25, the resident requested a change in code status from Full Code to DNRCC, but the request was not implemented at that time. The resident’s signed DNRCC form was not completed until 02/03/26, showing DNRCC-A, and physician orders and the care plan were updated to DNRCC-A on 02/10/26. The DON and Social Services confirmed the resident’s request for a code status change was not followed up on during the care conference and was only addressed later when the new code status form was completed.
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