Failure to Update EHR Code Status to Match Resident's POLST Form
Penalty
No penalty information released
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Summary
The facility failed to update a resident's code status in the electronic health record (EHR) from Full Code to Do Not Resuscitate (DNR) after the resident's POLST form was changed to indicate No CPR. Staff interviews revealed that there was no clear process in place for updating the EHR when a resident's code status was changed on the POLST form, and staff were unclear about whose responsibility it was to ensure the EHR matched the resident's documented wishes. A review of the resident's EHR showed the code status remained as Full Code, while the POLST form indicated No CPR. Facility policy required that advanced directives and resuscitation status be documented in the medical record, but this was not followed in this instance.