MDS Alert

Make sure your facility’s protocol is up to snuff to avoid legal action and F155

End-of-life care is in the midst of a sea change in both society and our medical culture. Although the current RAI Manual does not mention instructions on DNR (do not resuscitate) or POLST (physician orders for life-sustaining treatment) forms, nor are they mentioned in the MDS, some skilled nursing facilities are facing legal action, as well as fines and lowered ratings from state agencies after resuscitating residents with established advance directives.

Beware: In the past three years, at least two SNFs in Connecticut and Florida resuscitated residents with signed DNR forms. A Florida SNF was fined by the Florida Agency for Health Care Administration after staff performed CPR, used a defalcator, and called emergency medical services before finding the implicated resident’s DNR. The facility was also placed on a nursing home watch list.

The Department of Health and Human services’ most recent update to state operations Manual Appendix PP, released and made effective March 8, 2017, features a section focused on advanced directive procedures and compliance.

To avoid F155, your facility needs to meet the following criteria:

• Your facility must establish and implement policies and procedures regarding the right to formulate advance directives, refuse medical and surgical treatment and other related interventions and to decline to participate in experimental research;
• You or team members must inform and educate the resident about these rights, including the facility’s policies regarding exercising these rights;
• You or staff must determine whether the resident has an advance directive in place or has offered the resident the opportunity to develop an advance directive;
• You or staff must document when the resident is determined not to have decision-making capacity and therefore decision-making is transferred to the health care agent or legal representative;
• You or staff must help the resident to exercise these rights based on explaining risk and benefits of declining treatment;
• You or staff must incorporate the resident’s choices into the medical record and orders related to treatment, care and services;
• You or staff must consistently maintain advance directives and resident goals and in the same section of the clinical record or other document filing system for all appropriate residents, where those documents are easily retrievable by staff during both routine and urgent or emergent situations; and
• You or staff must monitor the care and services given to the resident to ensure that they are consistent with the resident’s documented choices and goals.

Caution: Pay attention to each resident’s particular wishes. Don’t perform CPR on a resident with a DNR, but don’t make “no CPR” the rule across your facility. The updated Appendix PP states that the “presence of a facility-wide ‘no CPR’ policy interferes with a resident’s right to formulate an advance directive and should be cited F155.”

Simple Fix: Establish facility-wide policy and protocol to have any DNR, POLST forms, or other advanced directives easily available and visible. If you’re interested in extra visibility, look into DNR bracelets, though regulations vary according to states.

Resource: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2017Downloads/R168SOMA.pdf.