Failure to Accurately Document and Maintain Resident Code Status
Penalty
Summary
The facility failed to accurately document and maintain the correct code status for two residents, resulting in discrepancies between the residents' wishes as indicated on their Iowa Physician Orders for Scope of Treatment (IPOST) forms and the code status recorded in the electronic health record (EHR) and physician orders. For one resident with diagnoses including metabolic encephalopathy, diabetes, hypertension, and respiratory failure, the IPOST form indicated a Do Not Resuscitate (DNR) status, while the EHR and physician orders listed the resident as Full Code. The Director of Nursing (DON) confirmed the inconsistency, noting that the resident's code status may not have been updated following hospitalizations. The facility's policy required routine review and updating of advanced directives, but this was not followed, leading to conflicting documentation regarding the resident's code status. For another resident, the IPOST form indicated a desire for Full Treatment and Cardiopulmonary Resuscitation (CPR), but the EHR listed the resident as DNR. Staff were unable to locate the resident's IPOST in the designated binders at either nursing station, and an LPN initially stated the resident was DNR based on the EHR. Upon further review, the LPN found the IPOST in the EHR, which showed the resident wished to be Full Code, and subsequently updated the EHR to reflect this. The facility's policy required that a copy of any advance directives be included in the medical record and that the care plan team be informed of any changes, but these procedures were not consistently followed, resulting in inaccurate documentation of residents' code status.