Best Practices for Establishing and Honoring Code Status

Best Practices for Establishing and Honoring Code Status

When a new resident arrives at your nursing facility, one of the most critical steps in the admission process is confirming and documenting their code status – the instructions for how medical providers should respond if the resident experiences a life-threatening event such as cardiac or respiratory arrest. This is not just a regulatory requirement; it is a resident rights and dignity issue that sets the tone for person-centered care.

Unfortunately, misunderstandings or delays in establishing code status can lead to confusion, medical errors, or even care that violates the resident’s wishes. By following best practices, facilities can ensure this process is done thoroughly, accurately, and compassionately.

1. Start the Conversation Early and Clearly

Include discussions about code status as part of the pre-admission process when possible. Obtaining information about advance directives should be included during intake before the resident arrives.

Use plain language and avoid medical jargon like “DNR” or “full code” without explanation. Instead, say, “If your heart or breathing stops, would you want us to try to restart it using CPR or other medical interventions?”

Be culturally sensitive. Some residents or families may have strong beliefs about end-of-life care. Approach the topic with empathy and without assumptions.

2. Confirm, Don’t Assume

Never rely solely on hospital discharge paperwork, especially if outdated. Always confirm with the resident or their legal representative what their current wishes are. Additionally, check for existing state-specific forms. In many states, documents like POLST (Physician Orders for Life-Sustaining Treatment), POST (Physician Orders for Scope of Treatment), or MOLST (Medical Orders for Life-Sustaining Treatment) must accompany the resident and be signed by a physician or nurse practitioner to be valid. If the resident lacks decision-making capacity, ensure the correct legal decision-maker (e.g., health care proxy, POA) is involved.

3. Document Thoroughly and Accurately

Code status is documented in multiple places, including admission paperwork, physician orders, the care plan, and the electronic health record. Verify that code status is accurately documented and updated in all areas of the medical record if the resident’s decision changes. If the resident chooses DNR, the care plan should reflect interventions focused on comfort and avoidance of resuscitation efforts.

Code status should be clearly visible to all care team members, both in the chart and in any bedside or emergency alerts your facility uses (while still maintaining privacy).

4. Involve the Interdisciplinary Team

Nursing should ensure accurate documentation and care plan updates. Social Services can help facilitate discussions and address emotional, spiritual, or cultural concerns. Medical Providers (physicians, NPs,

PAs) are responsible for writing and signing the official orders. Therapy, dietary, and activities staff should be aware of whether care plans have limitations tied to code status.

5. Review and Reconfirm Regularly

The resident has the right to change their mind about their advance directives, including code status, at any time. Revisit choices periodically and during significant changes in condition. Hospitalizations, new diagnoses, or declines in health are opportunities to review code status.

Honor changes immediately. If the resident or legal representative updates their wishes, orders and documentation should be revised without delay.

6. Train Staff on Emergency Protocols

Drills aren’t just for fire safety. Ensure staff know exactly what to do in an emergency, depending on the resident’s code status, and avoid “default to full code” errors.

For newly admitted residents, and in accordance with F678 – §483.24(a)(3), if the resident’s wishes are different than the admission orders, or if the admission orders do not address the resident’s code status and the resident does not want to receive CPR, facility staff should immediately document the resident’s wishes in the medical record and contact the physician to obtain the order.

While awaiting the physician’s order to withhold CPR, facility staff should immediately document discussions with the resident or resident representative, including, as appropriate, a resident’s wish to refuse CPR. At a minimum, a verbal declination of CPR by a resident, or if applicable, a resident’s representative, should be witnessed by two staff members, though individual States may have more specific requirements related to documenting verbal directives.

While the physician’s order is pending, staff should honor the documented verbal wishes of the resident or the resident’s representative regarding CPR.

In a high-stress moment, staff should be confident that they can quickly access and follow the resident’s wishes. Establishing and honoring code status is a core component of resident rights, regulatory compliance, and ethical care. By making it a priority at admission and maintaining vigilance throughout the resident’s stay, nursing facilities can protect residents’ autonomy, reduce risk, and foster trust with families.

When done right, this process is more than a check-box—it’s a commitment to respect, dignity, and person-centered care from day one. Contact Proactive for assistance in reviewing critical procedures and implementing effective compliance processes as part of a project engagement or on a 12-month annual partner plan.

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