Failure to Update Care Plan to Reflect 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 the care plan for a resident to reflect a change in code status from Full Code to Do Not Resuscitate (DNR) as ordered by the physician. The resident, who had a history of traumatic subdural hemorrhage and was assessed as having severely impaired cognition, was admitted with a care plan indicating Full Code status. However, a physician order for DNR with selective treatment was initiated, and this change was not reflected in the resident's care plan. Staff interview confirmed that the care plan had not been revised to match the current physician order, resulting in a discrepancy between the resident's documented treatment preferences and the care plan.