Failure to Address Conflicting Code Status Orders Resulting in Unwanted CPR
Penalty
Summary
The facility failed to implement corrective action after identifying that staff maintained inaccurate and inconsistent code status information in residents' medical records. This deficiency resulted in residents receiving unwanted Cardiopulmonary Resuscitation (CPR). In one instance, a resident's medical record contained two active Maryland Orders for Life Sustaining Treatment (MOLST) forms with conflicting code statuses—one indicating full code and another indicating no CPR. When the resident was found unresponsive, CPR was initiated despite the resident's documented wish not to receive it. The medical record also lacked documentation of the time CPR was started. A subsequent audit revealed additional residents with more than one active MOLST and conflicting code status physician orders. The process for updating and voiding MOLST forms and corresponding orders was not consistently followed, and not all nursing staff received education on the correct procedures. Despite the identification of these issues, the facility's Quality Assurance Performance Improvement (QAPI) committee meeting minutes over an eleven-month period did not document discussion or follow-up on the performance improvement plan (PIP) created to address the problem. In another case, a resident with an active MOLST indicating no CPR had conflicting physician orders in the medical record, including an order for full code that remained active until the resident coded. The resident received unwanted CPR for twelve minutes. The DON did not fully investigate the incident to determine the cause or ensure corrective action was taken. The QAPI committee failed to review or address this system breakdown in their meetings, and there was no evidence of actions taken to prevent recurrence.