Failure to Accurately Update Advance Directive Status in Medical 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 status was accurately reflected in all parts of the medical record. One resident, who was cognitively intact and had multiple diagnoses including respiratory failure, dementia, lung cancer, and COPD, had a Do Not Resuscitate (DNR) order signed and witnessed in the electronic medical record. However, the resident's face sheet, also known as the banner, incorrectly listed the resident as full code rather than DNR. This discrepancy was identified during a record review and interview, where a social service worker acknowledged that the code status had not been updated following the resident's recent return from the hospital.