Failure to Accurately Reflect Advance Directives in Care Plan
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 ensure that a resident's advance directives were accurately reflected in the care plan, as required by policy. Record review showed that the resident's POLST form and physician order sheet both indicated Do Not Resuscitate (DNR) status, while the care plan incorrectly listed the resident as Full Code. During an interview, the Director of Nursing confirmed that the care plan was not accurate and acknowledged the discrepancy, stating that the resident was technically a DNR and that the care plan needed revision. The facility's policy requires that advance directives be addressed in the resident's plan of care, but this was not followed in this instance.