Failure to Document and Communicate Resident Code Status
Penalty
Summary
The facility failed to maintain a clear and accessible procedure for documenting and communicating a resident's code status and advance directives, as required by its own policy. For one resident, the code status was not documented in the designated sections of the medical record, including the face sheet, physician orders, and the code status book. During a medical emergency, staff were unable to quickly locate the resident's code status, resulting in a delay in initiating CPR. The resident's admission baseline care plan indicated full code status, but this information was not consistently reflected or easily accessible in other required documentation locations. Multiple staff interviews confirmed that code status information should be available in the resident's chart, on the door, and in the code status book at the nurses' station, with all sources matching. However, staff reported that the Social Services Director (SSD), who was responsible for updating and auditing code status information, had not been in the position for some time, leading to discrepancies and outdated records. The newly hired SSD was in the process of auditing and updating code statuses, but at the time of the incident, the information was not current or consistent across all required locations. During the emergency, the LPN was unable to find the resident's code status after searching the physician orders, face sheet, and code status book, resulting in a delay of approximately five minutes before CPR was initiated. Other staff corroborated the difficulty in locating the code status and the expectation that this information should be readily available and consistent. The lack of clear documentation and communication of the resident's code status directly contributed to the delay in providing appropriate emergency care.