Failure to Update Care Plan After Change in Code Status
Penalty
Summary
The facility failed to update and implement a comprehensive care plan for a resident following a significant change in condition, specifically when the resident's code status changed from full code to Do Not Resuscitate (DNR). Despite physician orders and documentation indicating the change to DNR and the resident's admission to hospice, the care plan continued to reflect the previous full code status. The care plan still included interventions such as initiating CPR and calling 911, which were no longer appropriate for the resident's current wishes and medical orders. Interviews with facility staff revealed that the MDS nurse was responsible for updating care plans after changes in condition, but the update was missed. The Director of Nursing acknowledged that the care plan should have been revised to reflect the new code status and that the oversight could have led to confusion among staff regarding appropriate actions in an emergency. The facility's policy required care plans to be updated to reflect resident-specific interventions and needs, but this was not followed in this instance.