Failure to Document Code Status for Residents
Penalty
Summary
The facility failed to document the code status for two residents, leading to a deficiency in the management of their medical instructions regarding resuscitation and other lifesaving measures. Resident #31, who was observed with a tracheostomy and dependent on a ventilator, did not have a physician's order (PO) for code status in their electronic medical record (EMR) or hard paper chart. Although a nurse identified the resident as a full code, this was not supported by a documented PO. The nurse found an admission sheet listing the resident as a full code, but acknowledged it was not a PO. Similarly, Resident #49, who was ventilator-dependent and had a history of traumatic brain injury and epilepsy, also lacked a documented PO for code status. Despite staff stating the resident was a full code, they could not provide evidence of a signed PO. The Admissions Director mentioned checking hospital EMRs for code status before admission, but this information was not translated into a formal PO. The Director of Nursing confirmed the absence of a PO for both residents and acknowledged the need for such documentation at the time of admission. The facility was unable to provide a policy related to code status.
Plan Of Correction
1. Resident #31 and Resident #49 had their [R] clarified with the resident/resident representative and physician by the Director of Nursing. A physician order was obtained and documented in the electronic medical record and a hard copy placed in the appropriate area of the paper chart on 12/18/24. An in-service education was conducted on 12/19/24 by the Director of Nursing for all nursing staff and interdisciplinary team members regarding obtaining a physician's order and the importance of accurate and readily accessible code status documentation, including the facility's process on obtaining, documenting, and verifying code status. Attendance was documented. It was determined by Root Cause Analysis that the deficient practice occurred as a result of not having a formalized process supported by policy regarding the documentation of code status. 2. All residents have the potential to be affected by the same deficient practice. A chart audit was conducted by the Director of Nursing and Unit Managers with the use of an audit tool on 12/19/24 for 100% of current residents to ensure physician's order and code status documentation was present, accurate, and readily accessible. Any issues identified were immediately corrected. 3. A policy and procedure on code status documentation will be developed by 1/15/2025 by the interdisciplinary team and the administrator to include: - Specific location within the medical record for code status documentation (e.g., first page of physician orders, designated tab). - Requirement for code status to be reviewed and updated upon admission, change in condition, and at least annually. - Process for verifying code status during emergencies. - Designated staff responsible for ensuring code status documentation is complete. - Process for obtaining physician order for resident code status. - The nurse admitting the patient will confirm the code status and will get an order from the physician. - The Code status will then be entered into the EMR. A hard copy of the code status will be filed in the designated section of the medical records and scanned into the EMR. - The Code status order will be a part of the admission orders. - During the admission review meeting, the unit manager will ensure that the accurate code status order is obtained from the physician and entered in the EMR and the hard copy of the Advance Directive and/or POLST are filed in the resident's medical record designated code status section and scanned into the EMR. - An alert Icon for the code status will be entered into the EMR as a visual cue. - During the admission, quarterly and significant change care planning meeting, the IDC team will confirm the Code status of the resident and ensure it is documented in the EMR and hard copy is scanned and properly filed into the medical record. - The Social Worker will confirm the code status of the resident when they complete their social assessment and ensure a copy of the code status is properly filed in the code status section of the resident's record. All nursing staff will be re-educated on the revised policy and procedure on Code status order and documentation by the Clinical educator or designee by 1/24/25. Education on new Policy and Procedure on Code status documentation will be integrated into the new nurse orientation program and annual education program by the Clinical Educator. 4. The Social Worker will perform a weekly audit using an audit tool of 10% of resident charts to verify code status order(s) and documentation compliance for 3 months, then monthly for 3 months. Results of the audit will be tracked and reported to the administrator, and will be presented to the Quality Assessment and Assurance Committee quarterly and to the QAPI committee monthly.