Inconsistent Documentation of Code Status Orders
Penalty
Summary
The facility failed to ensure that a resident's code status was consistently documented across all relevant medical records. Specifically, a physician's order indicated the resident was Full Code, while the POLST form documented the resident as Do Not Resuscitate (DNR). The resident's care plan further indicated the POLST was Full Code, creating conflicting information regarding the resident's wishes for life-sustaining treatment. The Director of Nursing confirmed the discrepancy between the physician's order and the POLST, acknowledging that both documents should be identical to accurately reflect the resident's wishes. The facility's policy requires that code status be clearly documented and communicated in all designated sections of the medical record, but this was not followed for the resident, who had multiple diagnoses including dementia, diabetes mellitus, gout, and polyneuropathy.