Care Plan Failed to Reflect Resident's DNR Status
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected their documented code status. Medical record review for a resident with multiple complex diagnoses, including chronic kidney disease, heart disease, and dependence on renal dialysis, showed that the resident had a signed Advanced Directives form indicating a Do Not Resuscitate Comfort Care-Arrest (DNR CC-A) status. This directive was also supported by a physician's order. However, the resident's care plan listed interventions for full resuscitative measures, including CPR and calling 911, which contradicted the resident's documented wishes and physician order. During an interview, the DON confirmed that the resident's care plan did not match the signed Advanced Directives form or the physician's order, and that the resident was care planned as a full-code instead of DNR CC-A. Facility policy requires that care plans be consistent with residents' documented treatment preferences and advance directives. This discrepancy was identified during a review of care planning for three residents, affecting one resident, and was investigated under a specific complaint number.