Failure to Establish Baseline Care Plans for Code Status Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans addressing code status were in place within 48 hours of admission for three residents. Each of these residents had complex medical conditions, including chronic respiratory failure, COPD, diabetes, morbid obesity, altered mental status, hemiplegia, cerebral infarction, atrial fibrillation, pulmonary embolism, and chronic kidney disease. Physician orders documented the code status for each resident—either full code or do not resuscitate (DNR)—at the time of admission or readmission. However, review of the care plans revealed that none of the three residents had a baseline care plan for code status established within the required 48-hour timeframe, with delays ranging from several days to over a week. Interviews with facility staff, including the Social Service Director, Assistant Director of Nursing, and Nursing Home Administrator, confirmed that the process for reviewing and documenting code status was not consistently followed. The admitting nurse was expected to review code status with the resident or their representative and include it in the baseline care plan, but this step was missed for the residents in question. The facility's policy required an individualized, person-centered baseline plan of care to be developed within 48 hours of admission, including code status, but this was not adhered to for the affected residents.