The resident died with conflicting instructions in their medical record. Their advance directive clearly stated "Do Not Attempt Resuscitation" if they had no pulse and stopped breathing. But their active care plan still ordered staff to "start CPR" if the resident's heart or breathing stopped.
Federal inspectors found the discrepancy during a complaint investigation completed October 7. The facility's own policy requires care plans to match residents' documented treatment preferences and advance directives.
Resident B had signed the DNR form on a date redacted from the inspection report. Their care plan, however, maintained full resuscitation orders that had been "initiated" and "revised and canceled" on dates that were also redacted. The plan included specific instructions: "if the resident's heart/breathing stops, please start CPR."
The resident died at 2:37 p.m., according to nurses' progress notes reviewed by inspectors.
During interviews, facility staff acknowledged the system had broken down. The Social Service Director told inspectors that when a resident's code status changes, "it should be uploaded into the resident's record and the plan of care should be updated at that time."
That didn't happen.
The Director of Nursing provided inspectors with the facility's advance directive policy, though it was undated. The policy states clearly that "the plan of care for each resident is consistent with his or her documented treatment preferences and/or advance directive."
It also requires that "changes or revocations of a directive must be submitted in writing to the administrator" and that "the interdisciplinary team will be informed of changes and/or revocations so that appropriate changes can be made in the resident medical record and care plan."
The policy existed. The resident had followed the proper procedure by signing the DNR form. The interdisciplinary team simply failed to update the care plan.
This type of documentation failure can have serious consequences for residents and their families. When emergency situations arise, nursing staff typically follow the most recent care plan instructions. If those instructions contradict a resident's stated wishes, staff may perform unwanted medical interventions.
DNR orders are among the most fundamental healthcare decisions residents make. They represent a person's choice about how they want to be treated in their final moments. When facilities fail to properly document and implement these directives, they undermine residents' autonomy and potentially subject them to medical procedures they explicitly rejected.
The inspection report doesn't indicate whether resuscitation was attempted on Resident B. The timing suggests it may not have been necessary - the resident's death was noted at a specific time, 2:37 p.m., without mention of emergency interventions.
But the documentation failure meant nursing staff had contradictory instructions until the moment of death.
Transcendent Healthcare of Boonville operates at 725 S Second Street. The facility was cited for failing to develop, review, and revise care plans as required by federal regulations governing nursing home care.
The citation stems from a complaint investigation, meaning someone reported concerns about the facility's practices to state health officials. Inspectors reviewed records for three residents regarding advance directives and found problems with one case.
The violation was classified as causing "minimal harm or potential for actual harm" affecting "few" residents. However, the classification system doesn't capture the full impact of care plan failures on residents who have made specific end-of-life decisions.
Advanced directive policies exist precisely because these situations are so important to residents and families. The facility's own written policy recognized this, requiring interdisciplinary team coordination to ensure care plans match residents' stated preferences.
Federal regulations require nursing homes to complete comprehensive care plans within seven days of assessment and to have them "prepared, reviewed, and revised by a team of health professionals." The regulation aims to ensure residents receive individualized care that reflects their needs, preferences, and medical conditions.
When facilities fail to update care plans after residents make advance directive decisions, they create a gap between what residents want and what their medical records instruct staff to do.
The Social Service Director's acknowledgment that code status changes should trigger immediate care plan updates suggests facility staff understood the requirement. The Director of Nursing's provision of the advance directive policy indicates the facility had written procedures for handling these situations.
Yet Resident B's care plan was never updated to reflect their DNR decision.
The inspection occurred as part of ongoing federal oversight of nursing home care. Facilities must correct cited deficiencies and submit plans showing how they will prevent similar problems in the future.
For Resident B, the correction came too late. They died with a care plan that didn't match their documented wishes about end-of-life treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Transcendent Healthcare of Boonville from 2025-10-07 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Transcendent Healthcare of Boonville
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