HospitalInspections.org

Based on policy and procedure review, medical record review, and staff interview, the facility failed to ensure an adequate medical record was maintained with accurate documentation related to code status change for 1 of 1 (N1) closed patient medical records reviewed.

Findings:

1. Policy titled, "Code Status" reviewed on 5/6/10 at 11:16 AM indicated on pg. 1, under Procedure section, "A member of the healthcare team must complete, sign, date and time a new Code Status Order form with each code status change. The old Code Status Order form should be marked 'invalid' by placing an X across the form and writing VOID and then sign, date and time."

2. Review of closed patient medical records on 5/6/10 at 12:15 PM, indicated Patient N1 (client named in complaint) was a 67-year-old who was admitted to the facility on 3/16/10 at 18:44 PM for respiratory distress and acute exacerbation of COPD. Documentation in the medical record included:
A. Physician's Order Sheet dated 3/22/10 at 10:30 AM, "no vent per patient, no BiPAP per patient."

B. per Code Status Order Form:
a. dated 3/16/10 at 20:00 PM, "Full resuscitative measures" was chosen and this form was signed by physician, son, and witness. At the bottom of this form is the statement "When code status changes, place an 'X' across this form, write void, then sign, date/time and complete a new Code Status Order Form."
b. dated 3/22/10 at 21:00 PM, "No resuscitative measures (DNR)" was chosen and this form was signed by physician. Lacked signature and date of patient/legal representative and signature of witness under the statement, "The above code status was determined following a discussion of the patient's medical status with the patient and/or family or legal representative."
c. referenced in C.a. above, dated 3/16/10 at 20:00 PM, lacked an 'X' across this form, the words void, signature, and date/time the code status was changed.

3. Personnel P2 was interviewed on 5/6/10 at 1:45 PM and confirmed when a new Code Status Order form is completed, the old one should be marked 'invalid' by placing an X across the form and writing VOID and then should be signed by the physician, patient or their legal representative, witness, and dated and timed. When this patient's code status was changed from "full resuscitative measures" to "no resuscitative measures (DNR)", the old and new Code Status Order forms were not completed as required per facility policy and procedure.