Failure to Maintain Accurate Code Status Orders in Medical Records
Penalty
Summary
The facility failed to ensure that resident medical records were accurate and complete by not having physician orders for code status in place for two residents. For both residents, although their Physician Orders for Life Sustaining Treatment (POLST) forms indicated 'Do Not Attempt Resuscitation (DNR),' there were no corresponding physician orders entered into the electronic health record system as required by facility policy. The Director of Nursing (DON) confirmed during interviews and record reviews that the DNR orders were missing from the residents' medical records and acknowledged that these orders should have been entered into the Point Click Care system. One resident was admitted with diagnoses including vascular dementia, a left femoral neck fracture, and acute respiratory failure with hypoxia. The other resident had an original admission date several years prior. In both cases, the POLST forms clearly documented the residents' wishes regarding resuscitation, but the absence of a physician order in the medical record represented a failure to maintain accurate and complete documentation in accordance with accepted professional standards.