Failure to Honor Resident Code Status Preferences
Penalty
Summary
The facility failed to honor residents' wishes regarding code status for two residents reviewed. For one resident with multiple complex diagnoses, including end stage renal disease and mental health conditions, the clinical record and care plan indicated full code status. However, the resident reported that since admission, no staff had discussed or educated them about code status, nor had they been asked to sign any related forms. The Director of Nursing Services (DNS) confirmed that there was no code status designation in the medical record and that the resident had not signed a code status form, despite facility policy requiring this on admission. For another resident with moderately impaired cognition and several chronic conditions, there was conflicting documentation regarding code status. Although the resident had signed a Do Not Resuscitate (DNR) form after discussing it with staff and a physician, the electronic medical record (EMR) and care plan continued to list the resident as full code. Interviews with nursing staff revealed that they would have initiated CPR based on the EMR, which had not been updated to reflect the resident's most recent wishes for DNR status. The DNS acknowledged that the nurse who witnessed the DNR form should have ensured the physician order was updated in the EMR, but this was not done. Facility policy required that residents be provided with information about their right to accept or refuse medical treatment and that advance directives be documented. In both cases, the facility did not ensure that residents' code status preferences were properly documented, communicated, and honored, resulting in a failure to respect their rights regarding medical interventions.