Failure to Accurately Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to ensure that residents' code status was properly documented and accurately reflected in their medical records, as required by facility policy. For one resident, who was cognitively intact and had multiple diagnoses including high blood pressure, hemiplegia, traumatic brain injury, and psychiatric conditions, there was no code status indicated in the electronic medical record and no physician's order for code status at the time of admission. The Director of Nursing confirmed that the social worker was responsible for completing the initial code status sheet, but since there was no social worker present during the resident's admission, the code status was not completed. Staff were expected to treat the resident as full code until the code status was clarified and completed. For another resident, also cognitively intact and with significant medical conditions such as heart failure, renal insufficiency, diabetes, and chronic lung disease, there was a discrepancy between the code status documented in different parts of the medical record. The computer system and care plan indicated the resident was full code, while the code status decision form, signed and dated, indicated the resident was DNR (Do Not Resuscitate). An LPN confirmed the inconsistency and stated that, in the event of an emergency, the resident would be treated as DNR based on the form, but also acknowledged the need to clarify the code status order due to the conflicting documentation. The facility's policy requires that code status be determined and documented upon admission, with communication to the interdisciplinary team and regular review during care plan conferences. The Director of Nursing stated an expectation that code status should be completed and accurate for all residents. The failure to complete and accurately document code status for these residents represents a deficiency in honoring residents' rights to make informed decisions about their care.