Failure to Update Care Plan with Resident's DNR Code Status
Penalty
Summary
A deficiency occurred when the facility failed to update a resident's care plan to reflect a change in cardiopulmonary resuscitation (CPR) code status. The resident, who had diagnoses including myasthenia gravis, diabetes mellitus, and hypertension, was cognitively intact at the time of the incident. Her care plan continued to indicate CPR/Full Code status, even after she communicated her wish to change to Do Not Resuscitate (DNR) status. The change was documented in the social work progress note and a Medical Orders for Scope of Treatment (MOST) form was signed to reflect the new DNR status. Despite the code status change being discussed with the social worker and documented in the resident's records, the information was not communicated to the MDS Nurse responsible for updating the care plan. The MDS Nurse was unaware of the change and stated that such updates were typically discussed in clinical or standup meetings, but this particular change was missed. The Director of Nursing and the Administrator both confirmed that code status changes were expected to be discussed in daily meetings, but could not explain why this update was overlooked, resulting in the care plan not being revised in a timely manner.