Failure to Ensure Consistent Communication and Documentation of Code Status
Penalty
Summary
The facility failed to ensure consistent communication and clarification of a resident's code status, specifically whether to perform cardiopulmonary resuscitation (CPR) or to follow a Do Not Resuscitate (DNR) order. The resident in question had moderately impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 10 out of 15. Multiple documents in the resident's record, including the care plan, IPOST form, resuscitation designation orders, and physician orders, contained conflicting information regarding the resident's code status. Some records indicated the resident was a full code, while others indicated DNR status. Additionally, staff interviews revealed uncertainty and confusion about the resident's current code status, with staff referencing both full code and DNR in different contexts. Observation of staff interactions with the resident showed that the resident was unable to provide a clear answer regarding her wishes for resuscitation and requested that the nurse follow up with her family. Review of the code status book in the dining room also revealed the presence of both DNR and full code documentation for the same resident. The Director of Nursing acknowledged the mix-up and the need to clarify the correct code status. The facility's policy requires adherence to residents' rights to formulate advance directives and to implement guidelines regarding CPR, but this was not consistently followed in this case.