Failure to Maintain Accurate Code Status Documentation
Penalty
Summary
The facility failed to maintain accurate and consistent code status information for a resident with a history of malignant neoplasm of the uterus, anxiety, depression, and non-Alzheimer's dementia. Upon readmission, the resident had a physician's order for Do Not Resuscitate (DNR) status, and the resident's representative confirmed that this status had been in place since a hospital stay in January and had not changed. However, the resident's care plan was updated to indicate full code status, which conflicted with the physician's order and the representative's statements. Interviews with staff revealed that code status information was obtained from admission orders and hospital records, and was supposed to be reviewed with the resident or responsible party. The MDS nurse was responsible for updating the care plan, and the DON stated that code status was clarified on admission and during care plan meetings. Despite these procedures, the code status for the resident was missing from the red code status binder at the nurses' station, and staff relied on this binder to verify code status in emergencies. This inconsistency in documentation and communication led to the deficiency.