Failure to Update Resident Code Status in EMR After Change to DNR
Penalty
Summary
The facility failed to update the code status in the electronic medical record (EMR) for one resident who had requested a change from full code (CPR) to Do Not Resuscitate (DNR). The resident's Provider Orders for Life-Sustaining Treatment (POLST), signed by both the resident and physician, reflected the change to DNR. However, the code status displayed on the resident's dashboard in the Point Click Care (PCC) system continued to indicate full code. Staff, including an LPN and the director of nursing, confirmed that they rely on the PCC dashboard to determine code status in emergencies, and both acknowledged the discrepancy between the POLST and the dashboard information. The director of nursing stated that the new order for DNR should have been entered into the system but was missed following the resident's request during a recent appointment. Audits of code status are conducted only a few times a year, and the last audit occurred prior to the resident's change in code status. The facility's policy outlines the process for determining and documenting code status upon admission and during care planning but does not specify how staff should confirm code status in the event of a need for CPR.