Failure to Document Code Status for a Resident
Penalty
Summary
The facility failed to ensure that a physician's order was completed to indicate the code status for a resident, identified as Resident R26. The resident's electronic medical record (EMR) did not contain a physician's order specifying whether the resident was Full Code (CPR/Attempt Resuscitation) or Do Not Resuscitate (DNR/Do Not Attempt Resuscitation-Allow Natural Death). This deficiency was identified during a review of the facility's policy, clinical records, and staff interviews. The absence of a physician's order for code status was confirmed by both a Licensed Practical Nurse (LPN) and the Director of Nursing. Resident R26 was admitted with several diagnoses, including chronic respiratory failure with hypoxia, cardiac heart failure, diabetes mellitus type one, and constipation. Despite these significant health conditions, the EMR lacked a clear directive regarding the resident's code status. During interviews, it was noted that the EMR header indicated a status of DNI (Do Not Initiate), but this was not supported by a formal physician's order. The deficiency was noted under several Pennsylvania Code regulations related to management, resident rights, and medical records.
Plan Of Correction
1. Proper order for R26's code status was obtained and written on 12-19-24. 2. Facility reviewed all orders for all code status and any other issues were corrected on 12-19-24. 3. Education will be provided to nursing staff regarding obtaining the proper orders for code status. 4. Audits will be completed by Director of nursing or designee with all admits and any code status changes as the admits enter the building or code statuses are changed to ensure that facility has obtained the proper order for that code status. 5. Process will be monitored in QAPI meeting to ensure this process is sustained.