Inaccurate Documentation of Advance Directive in Clinical Record
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 directive regarding cardiopulmonary resuscitation (code status) was accurately documented in the clinical record. Upon review, the resident's electronic health record (EHR) listed the code status as FULL CODE, while the paper health record, specifically the hospital discharge summary, indicated DNR/DNI (do not resuscitate/do not intubate). During a joint review of the records by a surveyor and the Assistant Director of Nursing (ADON), it was confirmed that the EHR should have reflected DNR/DNI, not full code. The discrepancy between the electronic and paper records resulted in the resident's wishes regarding resuscitation not being clearly and accurately documented in the EHR.