Failure to Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to update and document the code status for a resident, resulting in the absence of clear information regarding the resident's wishes for resuscitation and life-sustaining measures. The resident's face sheet, orders, and progress notes did not contain any documentation of advance directives or code status at the time of admission or prior to the resident's death. Although a POLST form indicating Do Not Resuscitate (DNR) and comfort-focused care was prepared and signed by the resident, it was not signed by the medical provider until after the resident had expired. The Director of Nursing confirmed that the code status was not visible in the electronic health record and that there was no order for code status in the resident's records prior to death. The lack of timely documentation and communication of the resident's code status led to a situation where staff would have assumed full code status in the absence of clear orders, contrary to the resident's expressed wishes. The facility's policy requires that the POLST form reflect careful decision-making and be completed in consultation with the physician, but this process was not completed before the resident's death. The deficiency was identified through interviews and record reviews, which confirmed that the resident's preferences were not properly documented or accessible to staff at the time of the event.