Inconsistent Code Status Documentation for Resident
Penalty
Summary
The facility failed to ensure that a resident's code status was clear and consistent across all documentation sources. Clinical record review showed that the electronic health record (EHR) listed the resident as Full Code, while a physical document in a binder at the nurses' station indicated Do Not Resuscitate (DNR) status. The resident had diagnoses including non-Alzheimer's dementia, anxiety disorder, and depression, with a Brief Interview for Mental Status (BIMS) score of 0 out of 15, indicating severely impaired cognition. Staff interviews revealed that staff would check either the EHR or the binder at the nurses' station to determine code status, depending on which was more convenient. Facility policy required that resuscitation status be maintained in the clinical record, but the discrepancy between the EHR and the binder was not addressed prior to surveyor identification.