Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to ensure that accurate code status information was recorded and readily available for a resident. Specifically, a resident with a history of cerebral vascular accident and dementia, who had a moderate level of mental impairment, had conflicting documentation regarding their code status. The outside cover of the resident's hard clinical chart displayed a label indicating CPR should be performed in the event of cardiac or respiratory arrest, and a form inside the chart also included an order for CPR. However, a separate section of the chart contained an Iowa Physician Order for Scope of Treatment (IPOST) form, signed by the resident's durable power of attorney for healthcare and a healthcare practitioner, which indicated a DNR (Do Not Resuscitate) order. During staff interviews, it was revealed that the DON was unaware that the CPR identification label on the chart had not been updated when the resident began hospice care. Staff reported that in an emergency, they would refer to the label on the outside of the chart to determine whether to perform CPR. The facility's policy stated that residents have the right to make decisions regarding their healthcare, including CPR/DNR status, but the failure to update the chart label resulted in inconsistent and potentially misleading information about the resident's wishes.