Failure to Communicate and Document Resident Code Status Results in Inappropriate CPR
Penalty
Summary
The facility failed to ensure proper communication and documentation of a resident's code status, resulting in confusion among staff regarding whether to perform resuscitation efforts. The case manager did not immediately communicate the change in the resident's code status from Full Code to Do Not Resuscitate (DNR) after receiving a new POLST form from the resident's daughter, which was signed by both the resident and her attending physician. Additionally, the previous POLST indicating Full Code was not promptly removed from the electronic medical record (EMR), and the change in code status was not immediately documented in the EMR after verification with the resident and her daughter. This lack of timely communication and documentation led to conflicting information in the resident's medical records. When the resident became unresponsive, staff and emergency medical services (EMS) encountered two different POLST forms: one indicating DNR and another indicating Full Code. The EMS team questioned the validity of the DNR POLST due to a missing back page and ultimately relied on the Full Code POLST found in the EMR, leading them to initiate CPR, which was inconsistent with the resident's confirmed wishes. Interviews with facility staff revealed that the case manager acknowledged the failure to remove the outdated POLST from the EMR and to document the confirmed DNR status in a timely manner. Nursing staff were unaware of the voided status of the Full Code POLST and could not provide clear guidance to EMS during the emergency. The director of nursing also confirmed that the updated POLST had not been uploaded to the EMR. The facility's own performance improvement project identified root causes including dual POLST forms, incomplete documentation, and lack of clear workflow for verifying POLST accuracy during emergencies.