Failure to Accurately Document Resident Consent for Code Status Change
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for one resident. Upon admission, the facility's policy required that residents be provided with information about their right to formulate advance directives, and that any changes in decision-making capacity or code status be communicated and documented appropriately. A resident with diagnoses including malignant neoplasm of the brain, COPD, and chronic kidney disease was admitted and later had a code status change from full code to DNR. The resident was cognitively intact, as indicated by a BIMS score of 14, and was their own responsible party without a legal representative. On the date of the code status change, the POLST form was updated to DNR and signed by the resident's family member, despite the resident being their own responsible party. Progress notes indicated that the family member was involved in discussions and signed documentation, but there was no documentation in the clinical record confirming the resident's agreement to the code status change or to having the family member sign on their behalf. Staff interviews confirmed that the resident verbally agreed and nodded assent, but this was not documented in the clinical record as required by facility policy and professional standards.