Failure to Ensure Accurate Communication and Implementation of Code Status
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident was fully informed of, and able to participate in, decisions regarding their code status and advance directives. Record review revealed a discrepancy in the resident's medical chart, with conflicting information between the face sheet, care plan, OOH-DNR document, and physician orders. The face sheet and care plan indicated full code status, while a signed OOH-DNR was present in the electronic health record, and hospice orders were also noted. No DNR order was found in the physician orders section, and contradictory information was present regarding code status and hospice care. Interviews with the resident, social worker, DON, and administrator confirmed the existence of these discrepancies. The resident expressed a desire to receive CPR, while the chart contained a DNR order signed by physicians, without the resident's consent or presence at the last care plan meeting. The social worker and DON acknowledged the inconsistencies, and the administrator stated that records should be updated at care plan meetings, with the social worker responsible for ensuring accuracy. Facility policy requires residents to be informed and able to exercise their rights, but this was not followed in this case.