Failure to Update Care Plan with DNR Status
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that included measurable objectives and timeframes to meet the needs of a resident. Specifically, after an Out-of-Hospital Do Not Resuscitate (OOH DNR) order was signed by all appropriate parties, the resident's care plan was not updated to reflect the new DNR code status. The care plan continued to indicate that the resident wished to have CPR performed, and the interventions listed were not revised to align with the updated DNR order. Multiple staff interviews confirmed that the care plan should have been updated to reflect the resident's current code status, and that failure to do so could result in care that does not align with the resident's wishes. The resident involved was an elderly female with a diagnosis of unspecified dementia and a severely impaired BIMS score of 0. She was ultimately discharged due to death. Record reviews showed that the DNR order was properly signed and entered into the resident's chart, but the care plan was not updated accordingly. Staff interviews revealed that updating the care plan with the correct code status was a shared responsibility among the social worker, MDS nurse, and nursing staff, but in this instance, the update did not occur. The facility's policy required that the care plan reflect the resident's expressed wishes regarding care and treatment goals, which was not followed in this case.