Inconsistent Documentation of Code Status for Resident on Hospice
Penalty
Summary
The facility failed to ensure consistent documentation of code status for a resident reviewed for advance directives. The resident had a Code Status form indicating CPR, but the care plan did not include code status or mention hospice services. The resident's quarterly MDS assessment showed enrollment in hospice and severe cognitive deficits, while the Pocket Care Plan also directed CPR. However, the resident's chart binder was labeled as Do Not Resuscitate (DNR), and the electronic census confirmed the start of hospice services. During an interview, the ADON was unsure if the code status had changed with the initiation of hospice and acknowledged discrepancies in the documentation. Additionally, the facility did not have a policy on advance directives available.