Failure to Update Care Plan After Change in Code Status
Penalty
Summary
The facility failed to revise the individualized comprehensive care plan for a resident following a change in code status. The resident, who had diagnoses including dementia, anxiety disorder, and protein-calorie malnutrition, was admitted with significant cognitive impairment and required maximum assistance for most activities of daily living. Despite a physician's order changing the resident's code status to Do Not Resuscitate (DNR) and Do Not Intubate (DNI) and the resident's admission to hospice care, the care plan continued to reflect a status of Full Code. The care plan still included interventions such as performing CPR and reviewing code status quarterly, which were inconsistent with the new orders. Interviews with facility staff, including a CNA, LPN, Unit Manager, and Director of Nursing, confirmed that the care plan should have been updated immediately to reflect the change in code status. The Unit Manager acknowledged responsibility for updating the care plan, and the Director of Nursing confirmed that the care plan did not reflect the new DNR/DNI orders as required. Review of facility policy indicated that care plans must be comprehensive, person-centered, and updated to meet residents' needs, but this was not followed in this instance.