Failure to Accurately Reflect Resident Code Status in EHR
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected in the electronic health record (EHR) in accordance with the resident's completed POLST form. Upon review, the resident's POLST form indicated a preference for Do Not Attempt Resuscitation, while the EHR incorrectly listed the resident as Full Code/Full Treatment. Staff interviews confirmed that social services are responsible for reviewing and ensuring the accuracy of the POLST upon admission, and facility policy requires that any decisions regarding a resident's choices be documented in the medical record and communicated to the care team. However, this process was not followed, resulting in a discrepancy between the resident's documented wishes and the information available to staff in the EHR.