Failure to Maintain Accessible DNR Status in EHR
Penalty
Summary
The facility failed to maintain a complete and accurate clinical record for one resident when the resident's Physician Orders for Life-Sustaining Treatment (POLST), which indicated a Do-Not-Resuscitate (DNR) status, was not readily accessible in the resident's electronic health record (EHR). The resident reported having signed a POLST at admission, but during a review, a licensed nurse was unable to locate any code status in the EHR and stated that, in the absence of this information, the resident would be treated as a full code and receive cardiopulmonary resuscitation (CPR) if needed. The POLST form was later found in a binder at the nurse's station, but it had not been entered into the EHR or as a physician's order at the time of admission. The Director of Nursing confirmed that it was expected for a resident's code status to be readily available in the EHR and that, if not listed, the default assumption was full code status. The resident's care plan did indicate DNR status, but this information was not reflected in the EHR or physician orders, contrary to facility policy. The facility's policy stated that CPR and related emergency measures would not be used when a DNR order is in effect, but the lack of documentation in the EHR could have resulted in actions contrary to the resident's wishes.