Failure to Accurately Reflect Resident Code Status in EMR
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately reflected in the electronic medical record (EMR). Upon admission, the resident, who had diagnoses including depression, anxiety, and bipolar disorder and demonstrated intact cognition, signed a form electing Do Not Resuscitate (DNR) status. However, the EMR Profile tab and a physician's order both incorrectly indicated that the resident was to receive cardiopulmonary resuscitation (CPR), designating her as Full Code. Multiple staff interviews confirmed the discrepancy between the resident's documented wishes and the information in the EMR. The admitting nurse completed the Code Status Form with the resident, who clearly expressed a desire for no CPR, and the resident wore a DNR bracelet. Despite this, the order for CPR was entered into the EMR, and staff were unaware of the inconsistency. The Director of Nursing acknowledged that the process for verifying code status orders was not consistently followed, as staff were expected to refer to the completed Code Status Form and double-check the information entered into the EMR. The facility's policy required clear documentation of advance directives in designated sections of the medical record, but this was not adhered to in this instance.