Failure to Accurately Reflect Advance Directives in Clinical Record
Penalty
Fine: $91,3504 days payment denial
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 clinical record accurately reflected their advance directives. Record review showed that the resident was admitted with a diagnosis including normal pressure hydrocephalus and had a documented Do Not Resuscitate (DNR) status on both the admission record and a signed Louisiana Physician Orders For Scope of Treatment (LaPOST) form. However, the facility's Care Profile Report listed the resident as 'Full Code,' which conflicted with the DNR status documented elsewhere in the record. During an interview, the Director of Nursing confirmed the inconsistency and acknowledged that the Care Profile Report should have been updated to reflect the correct DNR status but was not.