Failure to Update Care Plan to Reflect Resident's DNR Status
Penalty
Summary
The facility failed to develop a comprehensive care plan that accurately reflected a resident's choice regarding code status. Although a physician's order and nursing progress note documented the resident's request for Do Not Resuscitate (DNR) status, the care plan continued to indicate Full Code status, which would require initiation of CPR. Interviews with the resident confirmed she had communicated her desire for DNR status to the facility. Both the RN and Unit Manager acknowledged that the care plan was not revised to reflect the resident's wishes, and the Director of Nursing confirmed that the care plan should have been updated at the time of the resident's request. This deficiency was identified for one resident whose advanced directives were not accurately documented in the care plan, despite clear communication and documentation of the resident's wishes and physician's orders.