Inaccurate Care Plan Documentation of Resident Code Status
Penalty
Summary
The deficiency involves the facility’s failure to ensure that comprehensive care plans were revised to accurately reflect residents’ current code status. For one resident with diagnoses including pressure ulcers and congestive heart failure, an active physician’s order and a POST form dated 12/8/25 documented a DNR (Do Not Resuscitate) status. However, the resident’s care plan created at admission on 10/20/25 contained an approach stating the resident’s code status as Full, while a later care plan dated 12/8/25 indicated a preferred code status of DNR, resulting in conflicting code status information within the care plan. For another resident with diagnoses including acute kidney failure and cerebral infarction, an active physician’s order dated 1/23/24 and an Indiana Out of Hospital DNR Declaration and Order form signed in 2022 documented a DNR status. Despite this, the admission care plan dated 1/19/24 included an approach listing the resident’s code status as Full, while a subsequent care plan dated 1/24/24 indicated a preferred DNR status. During interview, the Executive Director and DNS acknowledged that both residents’ care plans contained both Full Code and DNR designations and confirmed that the care plans should have been revised to reflect only the current DNR code status, contrary to the facility’s policy requiring periodic review and revision of care plan problems, goals, and interventions.
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