Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to maintain an accurate and consistent code status for a resident with a history of hypertension and dementia, who was assessed as moderately cognitively impaired. The resident's electronic health record, current physician's order, and care plan all indicated a Do Not Resuscitate (DNR) status, with documentation that a valid DNR was in place and interventions were aligned with this directive. However, a Physician Orders for Scope of Treatment (POST) form, signed and provided by the administrator, indicated that the resident was actually designated as full code, with instructions for CPR and full interventions, based on verbal consent from the resident's power of attorney (POA). The administrator was unaware of the conflicting information regarding the resident's advance directives, and the POST form was the only signed code status document available for the resident. The facility's policy required that advance directives be documented, maintained in the clinical record, and reviewed during care plan meetings, but this process was not followed, resulting in inconsistent documentation and a failure to honor the resident's or POA's most current wishes regarding code status.