Failure to Document Advance Directive Code Status on Admission
Penalty
Summary
The facility failed to ensure accurate and timely documentation of advance directives, specifically code status, for one resident upon admission. The resident, who had vascular dementia and Alzheimer's disease and was severely cognitively impaired, was admitted without an order or documentation regarding her code status for the first five days of her stay. Although the resident expressed a wish to be Do Not Resuscitate (DNR), she had an appointed guardian and was unable to make medical decisions herself. Interviews with facility staff revealed that the admitting nurse was responsible for completing advance directive forms and entering code status orders, and that a physician order was required for code status. However, review of the resident's record confirmed that no such order was present during the initial days of admission. Staff interviews further indicated that, according to facility policy, a resident is considered full code until a DNR form is signed by both the resident or their representative and the physician. The absence of a code status order was confirmed by multiple staff members, and the order for full code was only added after the deficiency was identified. The facility's policy required that code status be established and documented as part of the admission process, but this was not followed in the case of this resident, resulting in a lack of clear documentation regarding life-sustaining interventions during a critical period.