Failure to Ensure Consistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure clear and consistent direction regarding the code status of a resident, resulting in conflicting documentation and confusion among staff during a medical emergency. The resident had an IPOST indicating Do Not Resuscitate (DNR) status, while a physician's order in the facility's system listed the resident as Full Code, directing that CPR should be performed if the resident's heart or respirations stopped. The care plan also indicated the resident's desire to be DNR per IPOST, with instructions for regular review and updates. During an incident where the resident exhibited abnormal respirations and changes in color, staff responded by calling a code blue and preparing to send the resident to the hospital. Staff members discovered the discrepancy between the IPOST (DNR) and the physician's order (Full Code) at that time, leading to uncertainty about the appropriate response. Staff interviews revealed that the IPOST was signed after the resident's return from a prior hospitalization, while the Full Code order was entered upon that return, possibly due to hospital requirements for a procedure. The facility's policy required that advance directives be respected and that any such documents be included in the medical record, with periodic review and updates. However, the lack of alignment between the IPOST, physician's order, and care plan resulted in staff confusion during a critical event, as they were unsure which directive to follow. The issue was acknowledged by facility leadership, who noted the discrepancy and began reviewing other residents' records for similar issues.