SPARTA, NC- ALLEGHANY CENTER

Honor the resident’s right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 35789

Based on medical record review, staff interviews, and review of the facility’s Advance Directive policy the facility failed to provide written advance directive information and/or opportunity to formulate an advance directive and also failed to ensure a residents code status election was evident and accurately documented in the medical record for 10 of 10 (Resident #7, #12, #25, #27, #50, #63, #67, #71, #73, and #84) residents reviewed for advance directive.

a. Resident #50 was admitted to the facility on [DATE].

Review of a physician order dated [DATE] read, Advanced care planning-goals of care refer to state form.

The order did not explain where the form was kept.

Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #50 was severely cognitively impaired for daily decision making and had long/short term memory problems.

A review of the facilities advanced directives book that was kept at the nursing station revealed a Medical Order for Scope of Treatment (MOST) form that indicated Resident #50 desired CPR. The form was signed by the Medical Provider.

A review of the active physician’s orders revealed there was no order for Resident #50 to be a full code (desired CPR).

Resident #50’s medical record was reviewed with no evidence that written information regarding advance directives had been offered or discussed and no evidence of the guardian being given an opportunity to formulate an advance directive.

d. Resident #63 was admitted to the facility on [DATE].

A review of the facilities advanced directives book located at the nursing station revealed a Medical Order for Scope of Treatment (MOST) form dated [DATE] that indicated Resident #63 was a Do Not Resuscitate (DNR).

A review of the active physician’s orders revealed there was no order for Resident #63’s to be a DNR.

The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #63 was moderately cognitively impaired.

Resident #63’s care plan dated [DATE] revealed goals and interventions for cardiopulmonary resuscitation to be implemented.

Resident #63’s medical record was reviewed with no evidence that advance directive information had been offered or discussed and no evidence of the resident/guardian being given an opportunity to formulate an advance directive.

e. Resident #27 was admitted to the facility on [DATE].
The annual MDS dated [DATE] revealed Resident #27 was moderately cognitively impaired.

Resident #27’s physician’s orders were reviewed and revealed an order for Cardio-pulmonary Resuscitation (CPR) had been entered on [DATE].

Resident #27’s care plan dated [DATE] revealed goals and interventions for Do Not Resuscitate (DNR) to be implemented.

A review of the facilities advanced directives book located at the nursing station revealed Resident #27 had a MOST form dated [DATE] that indicated Resident #27 was a DNR.

Resident #27’s medical record was reviewed with no evidence that advance directive information had been offered or discussed and no evidence of the resident/guardian being given an opportunity to formulate an advance directive.

An interview was conducted on [DATE] at 3:37 pm with the Social Worker (SW). The SW stated before the facility changed ownership in [DATE] the only advanced directive form used in the facility was the golden Do Not Resuscitate (DNR) form that was completed by the previous Nurse Practitioner (NP). She reported facility staff did not know how to fill out the MOST forms and were uncomfortable using them. Previously, an order for the resident’s code status was entered in the electronic health record (EHR), the golden DNR form was scanned into the EHR, the code status was visible on the EHR banner, and the paper copy was in the advanced directives book at the nurse’s station. She reported one change that was made by administrative staff after the change of ownership was to shred all golden DNR forms, staff were instructed to remove code status information from the EHR and utilize MOST forms only which were not scanned into the resident’s EHR, only kept in a book at the nurse’s station. She reported that now on admission, the Unit Manager/Admissions Nurse/Hall Nurse was responsible for completing the MOST form with the resident and/or resident representative. The SW stated that the MOST form initiative at the facility had fallen through the cracks because no one wanted to take ownership and responsibility for the process.

An interview was conducted on [DATE] at 9:46 pm with Nurse #1. She reported the Corporate Nurse had told the facility staff not to use the golden DNR forms anymore and to only utilize the MOST forms. She was instructed by the Corporate Nurse to place a physician’s order for advanced care planning, stating to refer to the MOST form in the EHR and to complete a MOST form for all residents in the facility. She verbalized that when the previous code status orders were removed from the EHR, it removed the code status from the profile and banner in the EHR as well. She reported the only way to currently identify a resident’s code status was to physically look in the advanced directives book at the nurse’s station. Nurse #1 stated she did not feel comfortable with the new process and verbalized that to the Director of Nursing (DON). She stated that DON
got clarification again from the Corporate Nurse and confirmed that was the process that was to be
implemented, so Nurse #1 stated she did as she was instructed. Nurse #1 was unaware that Resident #63 code status was documented incorrectly on the care plan and Resident #27’s code status was documented incorrectly under orders in the EHR.

An interview was conducted on [DATE] at 12:13 pm with the Corporate Nurse. She reported that when the new corporation took over, the facility was not using MOST forms and only utilized the golden DNR forms. The new administrative staff implemented the use of the MOST forms in December of 2023. She reported that when a resident was admitted , the admission nurse or hall nurse went over the MOST form with the resident or the resident representative, the provider signed the form, the family signed the form, the form was scanned into the EHR, and then the paper copy of the MOST form was placed in the advanced directives book at the nurse’s station. The Corporate Nurse discussed she did not feel comfortable with code status information being entered into the EHR because of possibility of discrepancies. She indicated Nurse #1 was
responsible for entering the code status in the EHR after the MOST form was completed. The Corporate Nurse verbalized that there had been confusion with Nurse #1, and she had misunderstood the instructions which were to complete the MOST form and enter an order for code status in the EHR. The Corporate Nurse was unaware that Resident #63’s code status was documented incorrectly on the care plan and Resident #27’s code status was documented incorrectly under orders in the EHR. She reported that there should be an order in the EHR that indicated if the resident was a full code or DNR and the MOST form should be scanned in to the EHR.

An interview was conducted on [DATE] at 12:45 pm with the Director of Nursing (DON). The DON reported that advanced directives were not scanned into the EHR, should not be on the banner of the EHR, and an order should be entered into the EHR that instructed the staff to refer to the MOST form. The DON explained this was directed by the Corporate Nurse. She stated that Nurse #1 who was asked to remove all code status information from the medical record had expressed to her that she did not feel comfortable doing what was asked of her. The DON stated she again spoke to the Corporate Nurse and verified what the process was and relayed that information back to Nurse #1. She reported during a meeting on [DATE], she was instructed to enter advanced directive orders as DNR or CPR and had not gotten around to getting all those orders re-entered into the EHR.

An interview was conducted on [DATE] at 5:07 pm with the Administrator. She reported that it was the expectation that all advanced directive records matched in the EHR, care plan, and in the advanced directives book at the nurse’s station.