Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record regarding a resident's Advanced Directives and code status. When a resident with multiple diagnoses, including cerebrovascular accident with hemiplegia, chronic atrial fibrillation, diabetes mellitus, and dysphagia, was found unresponsive and without a pulse, nursing staff were unable to readily locate or identify the resident's code status in the medical record. The resident's Physician's Orders did not document the code status, and there was no completed Medical Orders for Life-Sustaining Treatment (MOLST) form available at the time of the incident. The nurse involved reported being unable to find the code status in the medical record or Physician's Orders and assumed the resident was a Do Not Resuscitate (DNR) due to their illness. Interviews with facility staff confirmed that the resident had been admitted without a MOLST form and that, according to facility practice, residents are considered Full Code until a MOLST is completed. However, the code status was not identified in the Physician's Orders or prominently displayed in the medical record, as required by facility policy. The Director of Nursing acknowledged that the code status was not properly documented or displayed, and the issue was discovered during the facility's investigation into the incident.