Failure to Timely Update Care Plan Following Change in Code Status
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident following a change in code status from Full Code to Do Not Resuscitate (DNR). The resident, an elderly male with diagnoses including a lumbar vertebra fracture, dementia, heart disease, and hypertension, was admitted with Full Code status. Documentation showed that the resident was cognitively intact and required significant assistance with activities of daily living. The care plan initially reflected Full Code status, with interventions such as initiating CPR and calling 911 in the event of cardiac arrest. After a signed DNR order was obtained, the care plan was not promptly updated to reflect the new DNR status. Both Full Code and DNR statuses were present on the care plan for a period of time, and the DNR status was not added until several days after the order was signed. Interviews with nursing staff and the DON confirmed that the process for updating code status in the care plan was not followed in a timely manner. Staff described that the nurse receiving the code status change was responsible for updating the care plan, but this did not occur as required. The facility's policy required care plans to be updated immediately upon a change in status, with audits to ensure compliance. However, the care plan for this resident continued to reflect outdated information, and the DON acknowledged that the care plan should have been updated sooner. During this period, the resident experienced an unwitnessed fall, though no injury was noted. The deficiency was identified through interviews and record reviews, which demonstrated a lack of timely care plan revision following a significant change in the resident's code status.