F0842

D

Failure to Accurately Update and Align Code Status Documentation

Schertz, Texas Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate clinical records regarding a resident’s code status in accordance with accepted professional standards. A female resident with diagnoses including unspecified dementia, depression, epilepsy, paranoid schizophrenia, and Alzheimer’s disease was admitted with documentation on her admission record, face sheet, care plan, electronic medical record opening page, and active physician orders all indicating a code status of Full Code. Her most recent MDS showed a BIMS score of 4, indicating severe cognitive impairment. Despite this, an out-of-hospital DNR (OOH-DNR) form signed by her responsible party was filed only under Miscellaneous documents in the electronic medical record, and the resident’s code status was not updated in the care plan, admission record, or active orders.

Further record review showed that a hospice interdisciplinary group meeting report listed the resident’s code status as DNR, but this information was not reflected in the facility’s primary clinical documentation or physician orders. In interviews, the Social Worker stated that code status would be addressed in care plan meetings and that she believed the MDS Nurse would update the care plan when a DNR was written. The DON reported that she downloaded DNR information into the resident’s file and kept hard copies, and 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 or why physician’s orders were not obtained. The MDS Nurse stated that no one had communicated that the resident’s code status had changed and suggested that hospice either did not write a DNR order or did not provide the information to the charge nurse to update the orders.