Failure to Ensure Immediate Access to Residents' Code Status in Emergencies
Penalty
Summary
The facility failed to ensure that residents' code status, specifically Do-Not-Resuscitate (DNR) orders, were clearly communicated and readily accessible to staff in the event of an emergency. For three residents with advanced directives, the DNR status was not entered as a physician's order or displayed in the designated code status bar within the electronic medical record (EMR). Instead, the DNR documents were filed under the miscellaneous tab, making them difficult and time-consuming for staff to locate during an emergency. In one instance, an LPN was unable to quickly find the code status for a resident, requiring several minutes to search through the EMR and ultimately referencing a paper binder kept in the DON's office, which was not immediately accessible. The residents involved had significant medical conditions, including Huntington's Disease, vascular dementia, adult failure to thrive, and encephalopathy, and were either totally incapacitated with court-appointed guardians or had signed their own DNR orders. Despite the presence of properly executed DNR documents, the lack of proper documentation and visibility in the EMR and other accessible locations meant that staff could not promptly determine residents' code status. The facility's policy required DNR orders to be documented in the resident's chart for staff awareness, but this was not consistently followed, as observed during staff interviews and record reviews.