Failure to Accurately Document Resident Code Status in EMR
Penalty
Summary
The facility failed to accurately document a resident's code status in the electronic medical record (EMR), resulting in a discrepancy between the resident's documented wishes and the information available to staff. The resident, who had a history of myocardial infarction and demonstrated intact cognition, had a signed Do-Not-Resuscitate (DNR) order on file, which was also reflected in multiple physician progress notes. However, the EMR information page incorrectly listed the resident as Full Code following a hospital readmission, due to an error made during the update of the resident's status. Interviews with nursing staff, including LPNs and the Unit Manager, confirmed that staff rely on the EMR information page to determine code status in emergency situations. The Director of Nursing also acknowledged that the EMR was marked inaccurately and that the resident should have remained a DNR according to their wishes. The facility's policy recognizes the right of residents to self-determination and to have advance directives respected, but this was not upheld in this instance due to the documentation error.