Failure to Accurately Document Resident Code Status in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's wishes regarding code status were accurately documented and reflected in the electronic medical health record. Specifically, a review of the resident's records showed that although the resident and their responsible party had indicated a desire not to have CPR performed, the electronic medical record, including the order entry, profile header, and care plan, continued to list the resident as a full code with instructions to begin CPR in the event of an arrest. The facility's policy required that code status be communicated and documented in designated sections of the medical record, but this was not followed in this case. The resident involved was admitted with diagnoses including metabolic encephalopathy, obesity, and schizoaffective disorder, and was assessed as cognitively intact with a BIMS score of 14. During an interview, the resident clearly stated they did not wish to have CPR performed. Despite this, the documentation in the electronic medical record did not reflect the resident's wishes, as confirmed by the DON, who acknowledged the discrepancy between the resident's expressed wishes and the information recorded in the system.