Failure to Honor Resident's Advance Directive Due to Inaccurate Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's advance directive and code status were accurately reflected and communicated among staff and in the electronic medical record (EMR). Although the resident had a completed and signed Do Not Resuscitate (DNR) order and was admitted to hospice care, the EMR, care plan, physician's orders, and code status book all indicated the resident was a full code, meaning all resuscitative measures would be taken in the event of a medical emergency. Multiple staff members, including LPNs, the MDS Coordinator, and the DON, all referenced the EMR and code status book, confirming that they would initiate CPR based on the information available, which was inconsistent with the resident's documented wishes and hospice status. Interviews with hospice nurses revealed that the resident had been DNR since admission to hospice, and there were signed DNR documents present. However, the facility's process for verifying and updating code status failed, as staff relied on outdated or incorrect information in the EMR and code status book. This discrepancy placed the resident at risk of not having her end-of-life wishes honored, as staff would have performed resuscitative measures contrary to the resident's documented DNR status.