Conflicting Advance Directive Documentation for Code Status
Penalty
Fine: $15,935
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 directive regarding code status was accurately documented in the clinical record. Upon review, the resident's electronic medical record indicated a Do Not Resuscitate (DNR) order, while the paper chart contained a Physicians Orders for Life Sustaining Treatment (POLST) form indicating Attempt Resuscitation/CPR. During an interview, an LPN was unable to determine which directive was correct, and the surveyor confirmed that conflicting information existed in the resident's records regarding their code status. This discrepancy in documentation resulted in the resident's right to formulate and have an accurate advance directive not being honored, as required.