Failure to Ensure Accurate Code Status in EMR Following DNR Documentation
Penalty
Summary
The facility failed to ensure the accuracy of code status information for a resident who was reviewed for advance directives. The resident, who had a history of hemiplegia, hemiparesis following a stroke, vascular dementia, and chronic kidney disease, was admitted with the ability to make their own medical decisions. The medical record initially reflected a physician's order indicating full code status. However, the resident and two witnesses later signed a Do Not Resuscitate (DNR) form, which was subsequently signed by the physician and scanned into the electronic medical record (EMR). Despite the completion and physician signature of the DNR form, the code status displayed in the EMR banner remained as full code, while the DNR form in the Miscellaneous section indicated DNR status. Interviews with nursing staff revealed reliance on the EMR banner for code status during emergencies, with one RN noting the discrepancy between the banner and the DNR documentation. The social worker responsible for advance directives acknowledged that the code status was not updated in the EMR banner after the physician signed the DNR form, possibly due to a lack of communication regarding the need to change the code status.
Plan Of Correction
F578 - Right to Refuse/Discontinue Treatment and Advance Directives Element #1: Resident #36's EMR was updated to reflect their current wishes for Advanced Directives. A reconciliation process was conducted between the documented code status and the banner in the EMR. Element #2: The Social Worker audited all residents to confirm accuracy in code status documentation. Any discrepancies were corrected and documented. Element #3: The policy Residents' Rights Regarding Treatment and Advanced Directives was reviewed and updated as necessary by the Administrator. Social Services and Licensed Nurses were educated on the policy and procedure. Element #4: The Social Worker or designee will review new physician orders weekly, Monday through Friday, for 12 weeks to ensure documentation is correctly reflected in all relevant systems. Any discrepancies will be reported in the audits and corrected immediately. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025