F0578

D

Inconsistent Code Status Documentation in Advance Directives

Rio Rancho, New Mexico Survey Completed on 02-11-2026

Penalty

Fine: $17,215

Summary

The facility failed to ensure that a resident’s advance directive information was accurate and consistent across the Electronic Health Record (EHR) and related documents. Record review showed that the resident’s face sheet listed the code status as Full Code at admission, indicating that lifesaving procedures were desired. The resident’s care plan, dated 11/03/25, also documented the resident as Full Code. However, the New Mexico Medical Orders for Scope of Treatment (NM MOST) form for the same resident, dated 05/05/23, identified the resident as Do Not Resuscitate (DNR), indicating that lifesaving measures were not desired.

During an interview, the DON acknowledged that the NM MOST form documented the resident as DNR while the face sheet and care plan documented the resident as Full Code. The DON confirmed that the resident’s correct code status was Full Code and stated that her expectation was that a resident’s code status be accurate and consistent across all documentation. The DON further stated that the NM MOST form was inaccurate and should not have been, confirming the inconsistency in the resident’s end-of-life documentation.