Failure to Accurately Document Resident Code Status and Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with professional standards for one resident. A review of the resident's records revealed a discrepancy between the code status documented in the electronic medical record, which indicated an Out-of-Hospital Do Not Resuscitate (OOH-DNR) order signed by a physician, and the resident's expressed wishes during an interview, where he stated he would want CPR. The resident had not signed any consents for Hospice or OOH-DNR, and the last care plan meeting did not include the resident's participation. The social worker and Director of Nursing confirmed the discrepancy and lack of updated documentation reflecting the resident's current wishes. The resident in question had a history of cognitive impairment, dementia, depression, and anxiety, with a BIMS score indicating moderate cognitive impairment and requiring supervision for daily activities. Despite this, the facility did not ensure that the resident's expressed wishes regarding code status were accurately documented or updated in the medical record. The facility's policy states that residents have the right to be fully informed about their care and treatment, but this was not followed in this case, resulting in incomplete and inaccurate records.