Failure to Maintain Accurate and Accessible Code Status Information
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accurate and readily accessible system for determining residents’ code status, specifically regarding whether cardiopulmonary resuscitation (CPR) should be initiated in an emergency. For one resident, admission documents showed a Medical Orders for Scope of Treatment (MOST) form indicating the resident was a full code and wanted CPR performed in an emergency, but there was no corresponding physician order for code status in the electronic medical record (EMR). The nurse rounding tool, which staff were expected to use when they did not have computer access, incorrectly listed this resident as Do Not Resuscitate (DNR). An LPN confirmed that staff were expected to enter a code status order upon admission, that MOST forms should be scanned into the EMR, that there was no code status order for this resident, and that the nurse rounding tool’s DNR designation did not match the resident’s MOST form indicating full code. For another resident, the MOST form and a physician’s order both documented that the resident was a full code and should receive CPR in an emergency, but the nurse rounding tool incorrectly listed this resident as DNR as well. The DON stated that staff were expected to look at residents’ MOST forms to determine code status and that there was a binder with MOST forms at another nurses’ station, but this binder was not readily available to staff on the skilled unit and did not contain the first resident’s MOST form. The DON also confirmed that the social services worker kept another binder with MOST forms in his office, which did include the first resident’s MOST form, and that for both residents the nurse rounding tool listed DNR despite their MOST forms indicating full code. The regional clinical nurse confirmed that MOST forms should be readily available at the nurses’ station and that nurse rounding tools should contain the correct code status for each resident.
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