Failure to Update Care Plan and Orders to Reflect Resident DNR Status
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident’s code status. The resident, an elderly female with severe cognitive impairment (BIMS score of 4) and diagnoses including unspecified dementia, depression, epilepsy, paranoid schizophrenia, and Alzheimer’s disease, was admitted with documentation in the admission record and care plan indicating a Full Code status. Her active physician orders also listed her as Full Code. However, the electronic medical record contained a DNR form signed by her responsible party, and hospice documentation from an interdisciplinary group meeting listed her code status as DNR. Interviews and record review showed that the change in code status to DNR was not communicated or incorporated into the resident’s care plan or active orders. The DON reported downloading DNR information into the resident’s file and keeping hard copies, and stated that either she or the MDS nurse would enter the code status into the care plan, but she did not know why this resident’s code status was not updated. The social worker stated that code status would be addressed in care plan meetings and believed the MDS nurse would update the care plan when a DNR was written. The MDS nurse stated that no one had communicated the code status change to him, suggested hospice may not have written a DNR order or informed the charge nurse, and noted he had been in the position for only two months and that no care plan meetings had been held prior to his tenure. As a result, the resident’s care plan and active orders continued to reflect Full Code despite existing DNR documentation.
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