Failure to Complete Code Status Form for Resident with DNR Order
Penalty
Summary
The facility failed to ensure that a completed code status form was present for a resident with multiple complex medical diagnoses, including ALS, chronic respiratory failure with hypoxia, COPD, pulmonary hypertension, malnutrition, major depressive disorder, and anxiety disorder. Although a physician order for Do Not Resuscitate Comfort Care Arrest (DNRCC-A) was written and present in the resident's medical record, the required code status form documenting this directive was not completed at the time of review. The resident was noted to have intact cognition, no behaviors, and was dependent on staff for all activities of daily living. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the form had not been completed prior to the surveyor's inquiry.