Description

Enhance CF758 regulatory compliance with this comprehensive chart audit tool. Systematically document, investigate, and address adverse outcomes involving failure to honor resident code status or advance directives to reduce your risk of deficiency citations.

Purpose-built to help facilities identify, review, and document all aspects of code status incidents, this tool enables a thorough evaluation of policies, staff training, resident care, and post-incident interventions to minimize risk and support regulatory compliance.

Key Features

• Step-by-step guidance for policy and procedure review
• Staff education and competency criteria
• Resident assessment and documentation protocols
• Immediate action checklists for adverse events
• Medication and diagnosis review
• Internal risk management and QAPI review
• Federal and external reporting guidance

Essential for facilities aiming to maintain compliance, protect residents’ rights, and avoid deficiency citations such as F758 (Free from Medication Errors/Failure to Honor Code Status). Demonstrate a proactive approach to resident autonomy, safety, and quality care.

This is one of the audits included in the Chart Audit Bundle which includes 18 chart audit tools: Pathway Health Chart Audit Bundle

Audits included in this bundle:

• F600–F610: Abuse Chart Review Audit Tool
• F684: Delay in Treatment Chart Review Audit Tool
• F689: Elopement Chart Review Audit Tool
• F578, F579, F580: Failure to Honor Code Status Chart Review Audit Tool
• F689: Falls Chart Review Audit Tool
• F609: Injury of Unknown Origin Chart Review Audit Tool
• F700, F909: Resident Adverse Outcome with Bedrails Chart Review Audit Tool
• F692: Resident Choking Chart Review Audit Tool
• F602, F603: Resident Exploitation Chart Review Audit Tool
• F684: Resident Fall Chart Review Audit Tool
• F684: Resident Fall Chart Review Reformatted
• F602, F603: Resident Misappropriation Chart Review Audit Tool
• F600–F610: Resident Neglect Chart Review Audit Tool
• F600–F610: Resident on Resident Altercation Chart Review Audit Tool
• F600–F610: Self-Harm Attempted Suicide Chart Review Audit Tool
• F757, F758: Significant Medication Error Chart Review Audit Tool
• F692: Significant Weight Change Chart Review Audit Tool
• F684: Unsuspected Death Chart Review Audit Tool