Failure to Accurately Reflect Code Status in Care Plan
Penalty
Summary
The facility failed to ensure that the care plan accurately reflected a resident's code status. A resident admitted with chronic obstructive pulmonary disease, diabetes, and a history of falls was identified in the social service assessment as a full code, but the signed advanced directive consent form indicated the resident's wishes were for Do Not Resuscitate (DNR). Despite this, the care plan listed the resident as a full code, and there were no physician orders on admission specifying the code status. The admission Minimum Data Set (MDS) assessment documented that the resident was moderately cognitively impaired and required varying levels of assistance with daily activities. During an interview and review of the care plan, it was confirmed that the care plan was incorrect and should have reflected the resident's DNR status. Facility policy required that code status be documented in writing after consent and that a physician's order be obtained, but these steps were not completed at the time of admission, resulting in the care plan not matching the resident's documented wishes.