LAMPASAS, TX - Lily Springs Rehabilitation and Healthcare Center encountered critical failures in managing a resident's advance directive that contributed to a patient's death when life-saving measures were not administered during a cardiac emergency.
Critical Documentation Failure Led to Improper Emergency Response
The most serious violation at Lily Springs centered on a devastating documentation error that prevented proper emergency medical care. A resident had formally requested to change his code status from "Do Not Resuscitate" (DNR) to "Full Code" during a care plan meeting, indicating he wanted all life-saving measures attempted in case of medical emergency. However, facility staff failed to update this critical information in the resident's medical records.
When the resident experienced a cardiac emergency on the evening he died, nursing staff followed the outdated DNR order in the computer system rather than his actual wishes. The resident "fell back in bed and became non-responsive" while speaking with Emergency Medical Services personnel who were already on scene treating him for chest pain and breathing difficulties. No CPR was performed because the electronic medical record still incorrectly showed DNR status.
This documentation failure represented an immediate jeopardy violation - the most serious category of nursing home deficiency that poses imminent risk of serious injury or death to residents. The facility's nurse stated during the investigation: "RN A checked in PCC, and it had DNR for Resident #1 and that was followed. RN A stated no CPR was performed because the code status in PCC showed DNR."
Breakdown in Care Planning and Communication Systems
The facility's care planning process revealed significant systemic problems. While the resident had clearly expressed his desire to change from DNR to Full Code during a formal care plan meeting, multiple staff members were unclear about their responsibilities for implementing this critical change. The Social Worker documented the resident's request and even removed the physical DNR form from the nurses' station, but the electronic medical record was never updated.
Investigation interviews revealed confusion among staff about who was responsible for updating advance directive information. The MDS (Minimum Data Set) Coordinator, who was identified as responsible for making such updates, was no longer employed at the facility when investigators attempted to interview her. The former Director of Nursing also could not be reached for comment.
The resident had intact cognitive function with a BIMS score of 14, indicating he was fully capable of making informed decisions about his medical care. His family member expressed devastation upon learning about the error, stating she was "blown away that EMS was right there with Resident #1 and could have possibly saved him."
Medical Significance of Code Status Documentation
Advance directives and code status designations serve as fundamental patient safety mechanisms in healthcare settings. These documents ensure that medical interventions align with patient preferences during critical moments when the patient may be unable to communicate their wishes. The distinction between DNR and Full Code status can literally mean the difference between life and death during cardiac or respiratory emergencies.
Full Code status means that all available life-saving measures should be attempted, including CPR, electrical cardioversion, advanced cardiac medications, and intubation. DNR status specifically prohibits chest compressions and artificial ventilation during cardiac arrest. When a patient changes their code status, immediate documentation in all medical records becomes essential because emergency situations leave no time for clarification.
The timing of this particular case made the documentation failure especially tragic. The resident was already receiving emergency medical treatment for cardiac symptoms when he suffered cardiac arrest. Emergency Medical Services personnel were present and equipped to provide immediate advanced life support, but the incorrect DNR designation in the facility's records prevented these interventions.
Nursing Home Industry Standards for Advance Directive Management
Federal regulations require nursing homes to maintain accurate advance directive documentation and honor resident preferences regarding medical treatment. The Centers for Medicare & Medicaid Services mandates that facilities must provide basic life support, including CPR, prior to emergency medical personnel arrival, subject to physician orders and resident advance directives.
Best practices in long-term care require immediate updates to advance directive information when residents change their preferences. This typically involves updating the care plan, notifying all relevant healthcare providers, and ensuring the electronic medical record reflects current patient wishes. Many facilities implement verification processes where multiple staff members confirm advance directive changes to prevent documentation errors.
The facility's own policy, revised in recent years, states that "Advanced directives will be respected in accordance with state law and facility policy." However, the investigation revealed that the policy was not effectively implemented, as staff training on care plan updates was inconsistent and responsibility for updates was unclear.
Response and Corrective Measures
Following the incident, facility leadership implemented comprehensive corrective actions. A facility-wide review of all resident advance directives was conducted to verify accuracy between resident preferences and documented code status. The facility held emergency quality assurance meetings involving the Medical Director, Director of Nursing, Administrator, and Corporate Clinical Specialists.
Staff training was expanded to include detailed instruction on updating code status within care plans and clear protocols for implementing advance directive changes. The facility established monitoring procedures requiring weekly audits of advance directive documentation for one month, followed by bi-weekly reviews for two months, then monthly ongoing assessments.
New hire orientation procedures were updated to include advance directive management training. The facility also implemented a Quality Assurance Committee meeting schedule to monitor compliance with the corrective action plan for eight weeks following the incident.
Additional Issues Identified
The inspection also documented violations related to care plan management beyond the advance directive failure. The facility had not properly care-planned the resident's code status even after he requested the change, representing a separate violation of federal care planning requirements. This compounded the documentation error and contributed to the tragic outcome.
Staff interviews revealed inconsistent understanding of care plan responsibilities among nursing personnel, suggesting broader systemic issues with care coordination and communication. The facility was required to evaluate the effectiveness of their corrective systems to ensure similar failures would not recur.
The inspection findings demonstrate how critical proper documentation and communication protocols are in nursing home settings, where vulnerable residents depend on staff to honor their healthcare preferences during medical emergencies. While the immediate jeopardy designation was eventually removed after corrective actions were implemented, the case serves as a stark reminder of the life-and-death importance of accurate medical record maintenance in long-term care facilities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Spring Oaks Nursing and Rehabilitation Lp from 2025-03-03 including all violations, facility responses, and corrective action plans.
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