Failure to Update Care Plan With Resident’s DNR Code Status
Penalty
Summary
Facility staff failed to revise and update a resident’s comprehensive care plan to include the resident’s current advance directive code status. Record review showed the resident was admitted with diagnoses including generalized idiopathic epilepsy with status epilepticus, depression, hypertension, and hypothyroidism. A Medical Orders for Scope of Treatment (MOST) form dated 02/11/2026 documented the resident’s code status as Do Not Resuscitate (DNR). However, the resident’s current care plan, dated 02/13/2026, did not include the active code status. Instead of documenting the resident’s DNR status, the care plan only indicated that staff would educate the resident and the resident’s Power of Attorney regarding health directives and have the physician complete a MOST form, despite the MOST form already being completed and specifying DNR. During an interview on 03/10/2026 at 2:14 pm, the DON stated it was her expectation that residents’ advance directives be included in their care plans and confirmed that this resident’s care plan did not include the advance directive code status and that it should have.
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