Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status information was consistent throughout the medical record. The resident, who had diagnoses including lung cancer, brain metastasis, cerebral edema, and seizure disorder, was cognitively intact and had previously signed an Advance Directive and had physician orders indicating Do Not Resuscitate (DNR) status. However, a later signed Medical Orders for Scope of Treatment (MOST) form indicated a change to full code status, meaning resuscitation should be attempted. Despite the resident's clear communication and understanding of the change in code status, the updated MOST form was not promptly communicated to the appropriate nursing staff or reflected in the electronic medical record (EMR). The Social Worker obtained the new MOST form but did not verbally notify anyone about the change. The facility's process required immediate notification of the DON or Unit Manager for such changes, but this did not occur, resulting in inconsistent documentation of the resident's code status across the medical record.