Failure to Accurately Document Resident Code Status in Medical Record
Penalty
Summary
Facility staff failed to maintain an accurate clinical record for one resident with multiple complex diagnoses, including congestive heart failure, ischemic heart disease, chronic kidney disease, peripheral artery disease, dementia, hypertension, anxiety, history of myocardial infarction, and osteoarthritis. The resident was assessed as having severely impaired cognitive skills. A physician's order was documented to change the resident's resuscitation status from full code to do not resuscitate (DNR). However, the electronic health record (EHR) did not reflect this change and instead listed the resident's code status as do not intubate (DNI), which was not supported by any physician order. The face sheet printed from the EHR also displayed the incorrect DNI status beside the resident's name. The social worker responsible for updating code status in the clinical records confirmed that the wrong selection was made in the EHR, resulting in the inaccurate documentation. The resident never had an order for DNI status, and the EHR failed to accurately reflect the DNR order that was in place at the time of the resident's death. This discrepancy was confirmed during staff interviews and review of the clinical record.