Failure to Implement Advance Directive Order
Penalty
Fine: $51,660
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 implement an advance directive (code status) order for a resident with multiple diagnoses, including heart failure, weakness, type 2 diabetes mellitus, and Alzheimer's disease. Upon review, the resident's record did not contain an order for an advance directive, despite documentation in the resident's profile and care plan indicating a desire to receive cardiopulmonary resuscitation (CPR). This omission was confirmed during an interview with the Director of Nursing, who acknowledged that the order had been missed. Facility policy requires that each resident's plan of care be consistent with their documented treatment preferences and/or advance directive.