Failure to Document Resident Code Status Upon Admission
Penalty
Summary
The facility failed to ensure that a newly admitted resident had a documented code status order in their medical record. Record review showed that the resident, who had diagnoses including hypertension and type 2 diabetes and was their own responsible party, did not have a code status order in their chart. Hospital records indicated the resident was a full code during their hospital stay, and the resident verbally confirmed their wish to be a full code and to have all interventions in place. However, this preference was not formally documented in the facility's records. An LPN acknowledged awareness of the resident's full code status from hospital records and stated that a POST form was prepared for the resident's family to complete. Although the family visited the facility, the LPN did not have time to have them fill out the necessary paperwork during their visit. Facility policy requires inquiry about advanced directives prior to or upon admission and assessment of decision-making capacity, but these steps were not completed as required, resulting in the absence of a documented code status for the resident.