Failure to Accurately Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to accurately document and maintain a resident's cardiopulmonary resuscitation (CPR) status. Review of the resident's electronic health record (EHR) showed a profile page indicating Do Not Resuscitate (DNR) status, but the scanned EHR documents included a DNR IPOST for a different resident. Physician orders contained a verbal order for DNR status, while the care plan indicated that the resident and their responsible party requested CPR to be initiated. Additionally, the IPOST in the facility's binder reflected a CPR status, with verbal consent from the legal healthcare representative and physician signature documented. Interviews with LPN staff revealed that code status information was accessed from both the EHR profile page and a physical IPOST binder at the nurses' station, depending on the situation. The facility's policy required validation of code status orders upon admission and quarterly, with appropriate state-approved DNR forms signed before entering a No CPR order in the EHR. The inconsistency and lack of accurate documentation across multiple sources led to confusion regarding the resident's actual code status.