Care Plan Failed to Reflect Accurate Code Status
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected the resident's current code status. According to the facility's policy, care plans are to be revised as information about residents and their conditions change. The resident was admitted with a care plan indicating full code status, but subsequent documentation in the electronic medical record, including physician orders and the facility dashboard, showed the resident was designated as do not resuscitate (DNR). The Minimum Data Set assessment indicated the resident was moderately cognitively impaired and unable to make decisions for herself, with her family member acting as the activated decision maker. Interviews with the resident's family member and the Social Services Director confirmed that the resident's code status was DNR and that the care plan did not accurately reflect this status. The Social Services Director acknowledged the inaccuracy of the care plan, and the Director of Nursing stated that her expectation was for the care plan to have the correct code status. This discrepancy between the care plan and the resident's current clinical status was identified through interviews, record review, and policy review.