Failure to Ensure Accurate and Consistent Documentation of Residents' Code Status
Penalty
Summary
The facility failed to ensure that all medical records accurately reflected the residents' wishes regarding code status for two residents. For one resident, the clinical record showed a LaPOST form indicating Full Code status, while the current physician orders and care plan documented Do Not Resuscitate (DNR). Multiple staff interviews confirmed the inconsistency between the LaPOST and the physician orders, and staff acknowledged that the documentation should have matched to reflect the resident's wishes. For another resident, the clinical record and care plan indicated Full Code status, but the physical hard chart contained both a LaPOST form indicating DNR and an advance directive form indicating Full Code. Staff interviews revealed that during an emergency, staff would refer to whichever form was on top in the chart, potentially leading to confusion. Staff responsible for updating code status documentation confirmed that only the most current code status should be present in the chart, and the presence of conflicting documents could result in staff not honoring the resident's actual wishes.