Failure to Ensure Accurate and Consistent Code Status Documentation and Communication
Penalty
Summary
The facility failed to ensure an accurate and consistent system was in place to direct staff when to initiate basic life support, including CPR, in accordance with physician orders and the resident’s advance directives. A resident was found unresponsive and without respirations by staff, who initiated CPR and called emergency medical services (EMS) and hospice. The resident’s facility medical record contained a full code status order, but there was no documentation of the resident’s wishes or consent for this status. In contrast, the hospice record at the facility showed the resident’s consent and an order for do not resuscitate (DNR), with documentation of a conversation reflecting the resident’s choice for DNR. Multiple inconsistencies were found in the documentation and communication of the resident’s code status. The admission paperwork was incomplete, and the baseline care plan did not address the code status. Staff interviews revealed confusion and lack of verification regarding the resident’s wishes, with some staff relying on incomplete or missing documentation in the electronic medical record (PCC) and others referencing the hospice binder, which was not always readily accessible. There was no documented contact with the resident, family, or physician to properly authorize a change from DNR to full code, despite conflicting information between facility and hospice records. Staff statements indicated that the process for documenting and communicating code status was inconsistent, with reliance on verbal reports, incomplete paperwork, and assumptions based on typical hospice practices. The hospice binder, which contained the resident’s DNR documentation, was not always in its designated location, further contributing to the confusion. The lack of a clear, unified, and accessible record of the resident’s code status led to the initiation of CPR against the resident’s documented wishes as per the hospice record.