Inaccurate Code Status Documentation in EHR
Penalty
Summary
The facility failed to ensure that the documentation in the Electronic Health Record (EHR) was accurate for a resident reviewed for advance directives. Specifically, the resident's code status in the EHR was documented as both Do Not Resuscitate (DNR) and Full Code, which are contradictory orders regarding life-sustaining measures. This discrepancy was identified during a review of the resident's EHR, which should have accurately reflected the resident's wishes as indicated in the Physicians Orders for Life Sustaining Treatment (POLST) and other medical records. The resident involved had a medical history that included acute respiratory failure with hypoxia, tracheostomy status, and dependence on a mechanical ventilator. During interviews, the Interim Director of Nursing (IDON) confirmed that the EHR was incorrect and should have only indicated DNR status. The IDON also stated that it was the responsibility of licensed nurses to ensure the accuracy of code status documentation in the EHR. Facility policy requires that clinical records be complete and accurately documented, but this standard was not met in this instance.