Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that all medical records accurately reflected residents' wishes regarding code status for two residents. For one resident, the physical chart contained a LaPost form signed by the resident's Power of Attorney and physician indicating Do Not Resuscitate (DNR), while the physician orders and electronic health record (EHR) listed the resident as Full Code. Staff interviews confirmed that the LaPost and EHR did not match, and the Director of Nursing acknowledged that all records should reflect the resident's end-of-life wishes but did not. For another resident, the physical chart's LaPost form indicated Full Code, while the hospice binder contained a LaPost signed by a family member and physician indicating DNR. The physician orders and EHR also listed DNR, but the physical chart did not match. Staff interviews revealed that in an emergency, staff would refer to the physical chart, which could result in actions inconsistent with the resident's wishes. The resident confirmed a desire for CPR, but documentation across records was inconsistent, and staff acknowledged that all records should be consistent.