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FAXTON-ST LUKE'S HEALTHCARE 1656 CHAMPLIN AVENUE UTICA, NY 13503 Dec. 22, 2015
VIOLATION: CONTENT OF RECORD - OTHER INFORMATION Tag No: A0467
Based on findings from document review, interview and medical record (MR) review, a change in the way providers order full code status was not effectively circulated throughout the medical staff. A policy and procedure (P&P) was not developed for this new process. Also, in 1 of 4 MR's reviewed, medical staff did not identify patient's code status on admission orders.

Findings include:

-- Per review of the facility's information bulletin titled "Code Status/Advanced Directives" posted 5/7/15-6/7/15 for providers, it indicated a "Full Code" is a new order and is intended to be used on all patients who wish to have all resuscitative means used in case of a respiratory or cardiac arrest. All adults should have a code status ordered. This was posted (on patient units and provider lounges) for all medical staff but the facility did not require attestation from medical staff indicating they had received the education. Additionally, no P&P was developed to address this bulletin.

-- Per MR review, Patient #2's Medical Orders for Life-Sustaining Treatment (MOLST), the patient's instructions were to be resuscitated if the patient had no pulse and/or was not breathing. However, the MR lacked a physician order for "Full Code" status.

-- During interview on 12/22/15 at 10:20 am with Staff I, the above findings were acknowledged.