Failure to Update Care Plan to Reflect DNR Status
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident's code status as Do Not Resuscitate (DNR), despite having physician orders and an advance directive consent from the resident's responsible party indicating DNR status. Instead, the care plan was initiated for full code, with interventions such as initiating CPR in the event of cardiac arrest, which contradicted the documented wishes and orders. This discrepancy was identified during a review of the resident's medical record and care plan by facility staff, who confirmed that the care plan did not align with the resident's documented DNR status. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease (COPD), severe protein-calorie malnutrition, anemia, hypertension, anxiety disorder, depression, and pain, and was unable to complete a mental status interview at the time of the deficiency.