Deficiency in Documenting and Accessing Residents' Code Status
Penalty
Summary
The facility failed to ensure that the code status of six residents was documented and accessible in their medical records, which could lead to miscommunication regarding their treatment preferences. For Resident #12, the electronic medical record (EMR) did not clearly indicate the resident's code status, and the physician's order only referred to a Preferred Treatment Option without specifying the details. Additionally, the care plan for Resident #12 did not mention the code status, and similar issues were found for Residents #21, #53, #79, and #158, where the EMR contained forms with options but lacked specific orders or care plans reflecting the residents' wishes. Resident #92, who had moderate cognitive loss and was receiving hospice services, also had no clear documentation of code status in the medical record. The Clinical Care Coordinator acknowledged the absence of specific orders or care plans for code status and mentioned that staff would need to search through the EMR or refer to a binder at the nurse's desk to find this information. However, the binder was not part of the official medical record, and the process of locating a resident's code status was cumbersome due to the binder's organization. During interviews, it was revealed that the binders containing code status information were difficult to navigate, and some documents, like the one for Resident #92, were of poor quality and unreadable. The facility's policy on Advanced Directives did not provide a clear process for ensuring that residents' code status was easily accessible in the medical record, contributing to the deficiency in maintaining accurate and accessible documentation of residents' treatment preferences.