Failure to Accurately Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to ensure that the code status for life-saving measures, including CPR, was accurately documented and consistently reflected for all residents, as required by policy and regulation. Specifically, for two residents, the electronic medical record (EMR), care plans, and physical indicators (such as door stickers and staff pocket care plans) did not match the residents' signed advance directives or physician orders. In one case, a resident who had a signed directive requesting full code status (CPR to be performed) was listed as Do Not Resuscitate (DNR) in the EMR and had a red dot on the door indicating DNR, while the daily staff pocket care plan listed the resident as full code. In another case, a resident who had a signed DNR order and advance directive was listed as full code in the EMR and on the staff pocket cheat sheet, contrary to the resident's wishes and physician's order. Interviews with staff revealed inconsistent knowledge and practices regarding how to verify and act on residents' code status. Medication aides and nurses relied on various sources, such as EMR, door stickers, and pocket care plans, but these sources were not always accurate or up to date. Some staff did not routinely check the code status before acting in an emergency, and there was confusion about which source was definitive. The Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that discrepancies existed between the signed code status documents and what was recorded in the EMR and other reference materials used by staff. The affected residents had significant medical histories, including conditions such as Parkinson's disease, diabetes, heart disease, and a history of heart attack. One resident was legally blind and had cognitive impairment, while the other had a history of cardiac issues and cancer. Both residents had clearly expressed their wishes regarding resuscitation, but the facility's failure to accurately document and communicate these wishes across all systems and to all staff created a situation where staff could have provided care that was contrary to the residents' directives.