Inconsistent Documentation of Advance Directive (Code Status)
Penalty
Summary
The facility failed to maintain consistent and accurate documentation of a resident's advance directive (code status) across both the electronic medical record (EMR) and the paper record kept at the nursing station. For one resident with a history of heart failure, renal insufficiency, and respiratory failure, the paper binder at the nursing station contained a signed Do Not Resuscitate (DNR) form, while the EMR and physician orders indicated a Full Code status. The care plan and recent assessments also reflected the Full Code status, despite the presence of the DNR form in the paper record. Interviews with facility staff revealed that both the EMR and the paper binder were used as sources for code status information, and staff expected these sources to match. Nursing staff and management acknowledged the discrepancy when it was brought to their attention, confirming that the two records did not align for this resident. The resident was noted to have moderately impaired cognition at the time of the deficiency.