Inaccurate Documentation of Resident Code Status in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to maintain a complete and accurate medical record regarding a resident’s code status. Facility policy on Code Status Orders states that code status communicates whether a patient desires CPR in the event of cardiopulmonary arrest. For one resident with diagnoses including hypertension, a history of falls, and malignant neoplasm of the bladder, the admission physician’s order summary documented a Do Not Resuscitate (DNR) status effective as of the admission date. However, the resident’s interdisciplinary plan of care, initiated after admission, documented the resident as "Full Code" with instructions to start CPR in the event of cardiac arrest. Further review of the clinical record showed that a progress note by the Social Services Director documented the resident’s advance directive as "Full Code," which conflicted with the physician’s DNR order. During an interview, the Nursing Home Administrator confirmed that the resident’s correct code status was DNR and that the documentation in the clinical record indicating a full code status was not accurate. This inconsistency demonstrated that the facility did not ensure the resident’s medical record was complete and accurately documented in accordance with professional standards and practices.
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