Failure to Update and Communicate Resident's Change in Code Status
Penalty
Summary
The facility failed to ensure that a resident's change in code status from full code to do not resuscitate (DNR) was properly communicated and updated in the medical record. According to facility policy, a DNR order must be documented as a medical order by a physician or authorized practitioner, and any changes to advance directives require immediate notification and documentation. However, review of the resident's care plan and physician orders indicated the resident remained listed as full code, despite discussions and documentation indicating a preference for DNR status. The resident in question had severe cognitive impairment and required extensive assistance with activities of daily living. Interviews revealed that the resident and family had discussed and signed DNR documents during the admission process, but staff failed to update the medical record accordingly. The Admissions Director explained that if the Physician Order for Life-Sustaining Treatment (POLST) form was unsigned, the default status was full code, and the process for obtaining physician signatures was unclear and not consistently followed. The Social Services Director confirmed that the POLST form was not properly dated or signed, and there was confusion about the process and documentation requirements. Further interviews with staff, including the Administrative Assistant and Administrator, highlighted gaps in communication and documentation regarding advance directives. The facility's process required collaboration between Admissions, Social Services, and physicians, but there was no clear timeframe or accountability for ensuring timely updates to the resident's code status. As a result, the resident's expressed wishes regarding resuscitation were not honored in the medical record, contrary to facility policy and regulatory requirements.