Failure to Accurately Document and Honor Resident Code Status on Admission
Penalty
Summary
A deficiency occurred when the facility failed to accurately document and honor a resident's code status upon admission. The resident, who was cognitively intact and admitted with diagnoses including infection related to a joint prosthesis, methicillin susceptible staphylococcus aureus infection, and hypertension, had a POST (Physician Orders for Scope of Treatment) form signed at admission indicating Full Code status. However, the physician order entered at the time of admission incorrectly documented the resident as DNR (Do Not Resuscitate), and the POST form was not present in the medical record as required. The care plan referenced the existence of advanced directives and DNR documentation, but did not reflect the resident's actual wishes as indicated on the POST form. The discrepancy was identified during a review of the medical record and confirmed through interviews with facility staff, including the medical record nurse and the DON. The facility's policy required the POST form to be maintained at the front of the resident's medical record, but this was not done, resulting in a failure to ensure the resident's treatment preferences were accurately recorded and accessible.