Failure to Ensure Consistent Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected throughout the medical record. Although the resident's advance directive care plan indicated a full code status, other documentation in the electronic health record (EHR), a physician's order, and the code status binder at the nurses' station all indicated a Do Not Resuscitate (DNR) status. The discrepancy was identified during a review of the resident's records and confirmed through staff interviews. Staff interviews revealed that the Social Worker (SW) and MDS Nurse were responsible for updating the advance directive care plan when a resident's code status changed. The SW acknowledged that the care plan was not updated to reflect the DNR status because the signed advance directives paperwork was not returned to her after being completed by the family. The Director of Nursing (DON) confirmed that the care plan should match the code status in the EHR and code status binder, and that the SW was responsible for updating the care plan when changes occurred.