Failure to Ensure Timely and Complete Documentation of Code Status and Advance Directives
Penalty
Summary
The facility failed to ensure that staff reviewed residents' medical records for code status, obtained physician signatures on code status orders, and uploaded code status documentation to the resident charts in a timely manner for two residents. In one case, a resident admitted with a right femur head and neck fracture was found unresponsive in bed. The nurse who discovered the resident did not know the resident's code status and had to check the computer to confirm DNR status. There was no signed advance directive or DNR consent form found in the resident's electronic medical record, and the Director of Nursing confirmed the absence of this documentation. In another instance, a resident admitted with orthostatic hypotension became unresponsive after experiencing shortness of breath and collapsing. Staff initiated CPR and used respiratory support equipment until another nurse checked the computer and found the resident was a DNR, at which point CPR was stopped. EMS requested code status paperwork, but it was not available in the digital chart, and the facility was unable to provide a signed advance directive or code status form for this resident as well. The facility's policy required staff to verify advance directives and obtain physician orders upon admission or after any change in preference or condition. However, in both cases, the required documentation was not present or accessible in the residents' records at the time of the incidents, leading to confusion and delays in following the residents' wishes regarding resuscitation.