Failure to Update Care Plan Following Change in Code Status
Penalty
Summary
A deficiency occurred when a resident's code status was not accurately reflected in the care plan. The resident, a 93-year-old female with diagnoses including traumatic subdural hemorrhage, severe unspecified dementia, and cognitive communication deficit, was admitted and later re-entered the facility. Her medical record indicated a DNR (Do Not Resuscitate) order with selective treatment, but the care plan continued to list her as having a Full Code status. This discrepancy was identified during a review of the resident's electronic chart and care plan documentation. An interview with an LPN and review of the care plan confirmed that the resident's code status had recently changed to DNR, but the care plan had not been updated to reflect this change. The care plan still instructed staff to treat the resident as Full Code, which was inconsistent with the current physician's order and the resident's wishes. This failure to update the care plan compromised the resident's right to have her treatment preferences honored.