Care Plan Not Updated to Reflect Resident's DNR Status
Penalty
Summary
The facility failed to ensure that a resident's comprehensive care plan was revised to accurately reflect the resident's code status as documented in the comprehensive assessment and the Physician Orders for Life-Sustaining Treatment (POLST). The resident, who was admitted with a primary diagnosis of acute pyelonephritis and demonstrated intact cognition, had a POLST form and MDS assessment indicating a Do Not Attempt Resuscitation (DNR) status. However, the care plan intervention continued to list the resident as Full Code, which was inconsistent with the resident's expressed wishes and documented orders. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that the care plan should have been updated to match the resident's current POLST. The discrepancy was identified during a review of the resident's records, and staff acknowledged that the care plan did not reflect the resident's actual code status as required by facility policy and assessment findings.