Failure to Collaborate with Hospice on Code Status Documentation
Penalty
Summary
A deficiency occurred when the facility failed to ensure proper collaboration with Hospice services regarding a resident's code status, resulting in contradictory documentation. The resident, who was cognitively impaired and had a terminal diagnosis, was admitted to Hospice services with a documented DNR (Do Not Resuscitate) order in the Hospice paperwork. However, the facility's electronic medical record (EMR) and care plan listed the resident as a full code, and current orders reflected this status as well. Discontinued orders and Hospice documentation indicated a DNR status, but this was not consistently reflected in the facility's records. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's correct code status. The RN relied on the EMR banner for code status information and was unaware of the DNR order in the Hospice paperwork. The Unit Manager and DON were also unaware that the DNR order had been provided by Hospice and could not recall or explain changes made to the code status in the EMR. There was no documentation of communication with the Hospice provider or the resident's representative regarding the code status, and staff could not provide a clear process for updating code status upon changes in care, such as admission to Hospice.