Failure to Update Care Plan to Reflect Resident's Code Status Change
Penalty
Summary
The facility failed to update the care plan for a resident to accurately reflect her current code status following changes documented in physician orders and the POLST form. The resident, who had multiple complex medical diagnoses including cerebrovascular accident, hemiplegia, COPD, heart failure, diabetes, and chronic kidney disease, was initially admitted as a full code. Subsequent physician orders and a signed POLST form indicated a change to Do Not Resuscitate (DNR) status and a decision not to hospitalize or send the resident out for appointments, as well as a referral to hospice care. Despite these documented changes, the resident's care plan continued to list her as a full code, and this discrepancy was not corrected in a timely manner. Record reviews and staff interviews revealed that the facility's policy required care plan updates within seven days of any change in condition or code status. The LPN interviewed confirmed that code status information is available in multiple locations, including the care plan, but acknowledged the care plan was not accurate. The Social Work Director also confirmed the care plan did not reflect the resident's current DNR and hospice status and was unable to explain how the update was missed. This failure to update the care plan was identified through review of records and staff interviews.