Failure to Ensure Consistent Code Status Documentation for Resident with DNR Directive
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's code status was accurate and consistent across the medical record. The resident, who was admitted for surgical aftercare and had multiple diagnoses including chronic kidney disease and atrial fibrillation, had a documented preference for Do Not Resuscitate (DNR) status as indicated on both the Advanced Care Directive form and the prehospital directive. Despite this, the electronic health record dashboard and physician order review listed the resident as Full Code, creating a direct conflict with the signed DNR documentation. Interviews with the resident confirmed her choice of DNR status. Staff interviews revealed that code status is typically verified using a code arrest book at the nursing station and the electronic health record dashboard. The registered nurse and social service supervisor both identified the discrepancy between the code book, which correctly reflected the DNR status, and the electronic health record, which incorrectly indicated Full Code. The Director of Nursing also confirmed the inconsistency after reviewing the relevant records and acknowledged that the code book and clinical record should match the physician's orders and the resident's wishes. Facility policy states that advance directives will be recognized and respected, but the process for updating and verifying code status failed in this instance. The baseline care plan did not note the resident's specific treatment preferences, and the weekly review process did not catch the discrepancy between the electronic health record and the code book. This failure resulted in the resident's documented wishes not being accurately reflected in all parts of the medical record.