Failure to Align Physician Orders with Resident's Documented Code Status
Penalty
Summary
The facility failed to ensure that physician orders were consistent with a resident's documented code status preference. A review of the clinical record for a resident with diagnoses including hypertension and epilepsy showed that the resident had completed and signed a CPR Status form indicating a preference not to receive cardiopulmonary resuscitation (CPR) if their heart or breathing stopped. Despite this, the electronic medical record contained a physician order listing the resident's code status as CPR, which was not in accordance with the resident's documented wishes. There was no evidence in the record that the resident had changed their decision or participated in any discussion to update their previously signed CPR Status form. The inconsistency between the physician order and the resident's expressed wishes was only corrected after it was identified by surveyors. The Nursing Home Administrator confirmed that physician orders are expected to match the resident's signed CPR Status form and acknowledged that the discrepancy should have been addressed prior to surveyor identification.