Care Plan Code Status Inconsistent With Resident’s DNR Advance Directive
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s plan of care was consistent with the resident’s documented treatment preferences and advance directive. The facility’s Advance Directives Policy stated that each resident’s plan of care would align with their documented treatment preferences and/or advance directive. Review of the medical record for Resident #68, admitted on 12/23/2025 with diagnoses including hypertension, neuroleptic-induced parkinsonism, protein-calorie malnutrition, and generalized anxiety disorder, showed a physician’s order dated 01/16/2026 for LaPOST-DNR (Do Not Resuscitate), and the resident’s face sheet also indicated DNR status. However, review of the resident’s care plan with a target date of 04/11/2026 documented the resident as “Full Code” and included interventions indicating the resident had an advance directive for Full Code. During an interview, the DON and the LPN/MDS nurse confirmed that, despite the DNR physician order and DNR status on the face sheet, the resident was care planned as Full Code and acknowledged the care plan code status should have been DNR instead of Full Code. This discrepancy between the resident’s documented DNR order and the care plan coding constituted a failure to honor and accurately reflect the resident’s advance directive and treatment preferences in the care planning process, as required by facility policy.
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