Failure to Update Care Plan Following Change in Code Status
Penalty
Summary
The facility failed to revise the comprehensive care plan to accurately reflect a resident's code status after a change in advanced directives. A resident with dementia was admitted with a care plan indicating a 'Full Code' status for CPR, while a physician's order was later entered into the electronic medical record by the Assistant Director of Nursing (ADON) changing the code status to Do Not Resuscitate (DNR). Despite entering the DNR order, the ADON did not update the resident's care plan to reflect this change. During interviews, the ADON acknowledged responsibility for updating the care plan and was unable to explain why it was not done. The Administrator confirmed that the care plan should have been updated when the DNR order was entered.