Failure to Ensure Accurate Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure that staff had access to an accurate code status for one resident reviewed for advance directives. Clinical record review showed that the resident had diagnoses including mild intellectual disabilities, heart failure, and depression, with a BIMS score indicating moderately impaired cognition. The facility's policy required advance directive orders to be kept in a binder accessible to nursing staff. During the survey, a registered nurse stated that code status would be checked first in the computer and then in the binder at the nursing station. However, the binder at the nursing station contained an IPOST form for the resident that directed staff to perform CPR, while both the electronic health record face sheet and the IPOST form itself indicated the resident wished to be DNR. The Director of Nursing confirmed that IPOSTs in the binders were expected to be accurate.