Failure to Update Resident Code Status After Responsible Party Request
Penalty
Summary
The facility failed to honor a resident’s right to change code status when the responsible party requested a change from do not resuscitate (DNR) to full code. The resident, who had been admitted earlier in the year, had a care plan revised on 3/19/25 that reflected a DNR status and a quarterly MDS assessment documenting severe cognitive impairment. During a care plan meeting on 11/25/25, the resident’s responsible party informed the MDS Nurse that she wanted the resident’s code status changed from DNR to full code, and the MDS Nurse documented this request in a care plan meeting note. Despite this documented request, the resident’s electronic medical record continued to display a DNR code status on the communication bar at the time of surveyor review. The MDS Nurse reported that she informed the Social Worker and the former DON about the responsible party’s request to change the code status, but she could not recall the specific date she did so. The Social Worker stated she was responsible for updating code status information in the electronic medical record and on the communication bar when a resident’s code status changed after admission. She also stated she was not present when the responsible party made the request, did not recall being told about the requested change, and confirmed that the code status had not been updated. During an interview, the Administrator acknowledged that the resident’s code status should have been changed when the responsible party requested it and described the failure to update the code status as an oversight.
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