Failure to Update Care Plan to Reflect Resident's DNR Status
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to update a resident's comprehensive care plan to accurately reflect the resident's current code status. The resident, who was cognitively intact and had diagnoses including hip fracture, compression fracture, and diabetes, was admitted with a care plan indicating 'Full Code' status, meaning CPR would be performed if needed. However, subsequent documentation, including a POST form and a physician's order, indicated the resident's preference for 'Do Not Resuscitate' (DNR) and comfort measures only. Despite these updated directives, the care plan was not revised to reflect the resident's DNR status. This discrepancy was confirmed during an interview with the Care Plan Coordinator.