Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status was consistently documented across the physician order, care plan, and POST (Physician Orders for Scope of Treatment) form. Record review revealed that the physician order indicated the resident was a full code, while the most recent POST form and care plan documented the resident as Do Not Resuscitate (DNR). The resident had a history of Huntington's Disease, anxiety, and dysphagia, and was noted to be cognitively impaired according to a recent MDS assessment. Interviews with facility staff confirmed the inconsistency, with the Administrator acknowledging that the POST form was correct and the physician order was incorrect. An LPN stated that the resident's code status changed frequently and updates were recorded in the medical record, but did not address the discrepancy between documents. Facility policy required that physician orders be specific and address each advanced directive, but this was not followed in the resident's case.