Failure to Document Resident Code Status in Medical Chart
Penalty
Summary
The facility failed to ensure that a resident's code status was documented in the medical chart, as required by facility policy. During an investigation, an LPN reported being unsure of the resident's code status because it was not listed in the chart or documented on the unit. A review of the resident's medical chart and physician order sheet confirmed that there was no code status or advance directive recorded. The resident's admission record also lacked this information. Interviews with the Regional Director of Clinical Services and the Director of Nursing confirmed that code status should be established and documented upon admission, and that it is a personal right of the resident and family. Facility policies require that physician orders, including code status and advance directives, be documented in the clinical record and physician order sheet. The failure to document the code status for this resident was identified through record review and staff interviews. The facility census indicated that 90 residents could potentially be affected by this deficiency.