Failure to Ensure Accurate and Consistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's code status information was accurate and consistent throughout the medical record and related documentation. The resident was admitted with a Do Not Resuscitate (DNR) order, as indicated in both the hospital discharge summary and the physician's orders. However, the DNR form was not present in the code status notebook kept at the nursing desk, which is used by nursing staff to quickly determine a resident's code status in urgent situations. When the nurse checked the notebook and did not find the DNR form, she would have determined the resident to be a full code, contrary to the documented DNR status in the medical record. Interviews with facility staff revealed that the Social Worker was responsible for auditing code status information, but the resident in question was not included in the most recent audit. The Social Worker could not explain why the resident was omitted, as the audit list was supposed to be generated directly from the medical record. Both the DON and the Administrator acknowledged the discrepancy between the medical record and the code status notebook, confirming that the resident's code status was not accurately reflected across all required documentation at the time of the survey.