Failure to Include DNR Status in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes for a resident with multiple medical conditions, including cancer, shortness of breath, and pain, who was also receiving hospice services. Despite the resident having a documented out-of-hospital do not resuscitate (DNR) order and a physician's order for DNR, the care plan did not reflect the resident's code status. The care plan review did not include this critical information, and there was no evidence that the interdisciplinary team had reviewed or updated the care plan to include the DNR status. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating the care plan with code status changes. The social worker stated she would update the care plan when code status changed, but had not signed off on the relevant section. The MDS coordinator acknowledged the absence of a code status care plan and indicated that it should have been included, noting that care plans are interdisciplinary documents. The administrator confirmed that the care plan should be person-centered and complete to ensure staff have the necessary information to provide proper care.