Failure to Maintain Accurate Code Status in Medical Records
Penalty
Summary
The facility failed to maintain accurate and up-to-date medical records regarding the code status and CPR directives for a resident with multiple complex diagnoses, including acute respiratory failure, pulmonary disease, congestive heart failure, chronic kidney disease, and diabetes. The resident was admitted to hospice care, and documentation indicated a change in code status to Do Not Resuscitate (DNR) with comfort measures, as reflected on a new POST form and hospice admission paperwork. However, the medical record and physician order sheet did not reflect this change, and the resident remained listed as full code in the facility's computer system. When the resident became unresponsive, staff initiated CPR based on the outdated code status in the computer system, and EMS continued resuscitation efforts. Interviews with facility staff confirmed that the process for updating and uploading new POST forms was not followed, and the new DNR order was not properly incorporated into the resident's medical record. This failure to maintain accurate and current medical records resulted in actions that were not consistent with the resident's documented wishes and hospice care plan.