Code status 'cheat sheet' draws scrutiny, nursing home challenges neglect finding

A “cheat sheet” to track residents' code status has become a source of controversy in the case of a Minnesota man who died without being given CPR, according to local news sources.

The resident — whose name has not been released — died on the morning of May 7 at the Pioneer Care facility in Fergus Falls. Two licensed practical nurses attended to him in the minutes before he died, but neither initiated cardiopulmonary resuscitation, a Health Department investigation determined.

One LPN later told a registered nurse at the facility that she had “forgotten” to check the resident's code status, the Minneapolis Star Tribune reported. The other LPN reportedly said she had been checking the man's vital signs when he passed away.

But even if they had checked, the nurses might not have known the man's code status due to documentation issues, the Health Department determined. Investigators found that a code status “cheat sheet” kept in a three-ring binder inaccurately indicated that he did not want life-saving measures, according to the Star Tribune. And his code status also had not been entered into his electronic medical record, the Health Department report stated. Only his actual consent form indicated that he desired CPR to be performed.

Administrator Nathan Johnson acknowledges that the incident “should have never happened,” but Pioneer Care is challenging a finding of neglect in this matter, the Star Tribune reported. This is because the finding is based largely on the cheat sheet, which Johnson says actually did not play any role in the failure to perform CPR. Pioneer Care suspended the LPN who forgot to check the man's code status and retrained its staff, and a subsequent survey found that the facility was in compliance, the newspaper reported.

Johnson had not responded to a phone call from McKnight's as of press time.