Failure to Update Care Plan to Reflect Resident's DNR/DNI Status
Penalty
Summary
The facility failed to ensure that a resident's person-centered care plan was reviewed and revised to accurately reflect the resident's current code status. Specifically, a review of the resident's electronic medical record revealed a physician's note and a signed MOLST form indicating the resident's code status as Do Not Resuscitate/Do Not Intubate (DNR/DNI). However, the active physician's orders and the care plan still listed the resident as Full Code, which is inconsistent with the documented advance directives and medical orders. This discrepancy was identified during a surveyor's review of the resident's records and confirmed in an interview with the Director of Nursing (DON), who acknowledged that the care plan had not been updated to reflect the resident's current wishes and medical orders. The failure to update the care plan occurred despite the presence of clear documentation in the medical record and MOLST form indicating the resident's DNR/DNI status.