Inconsistent Documentation of Resident Code Status
Penalty
Summary
The facility failed to ensure that a resident's code status was consistently and accurately documented across all medical records. Upon review, the resident's face sheet did not include any code status, while the hospital discharge documentation and the New Mexico Medical Orders for Scope of Treatment (NM MOST) form both indicated a Do Not Resuscitate (DNR) status. However, the resident's care plan listed a Full Code status. During the admission process, a family member was informed by a nurse that the resident was a full code, despite the family member's knowledge of a DNR status from the hospital. The Director of Nursing confirmed that the facility presumes full code status if no documentation is present and acknowledged the inconsistency in the resident's records.