Failure to Update and Reconcile Advance Directive and Code Status Documentation
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 and New Mexico Orders for Scope of Treatment (MOST) form were consistent with the physician's orders documented in the electronic health record (EHR). Record review showed that the resident's physician orders indicated a Do Not Resuscitate (DNR) status, while the current advance directive and MOST form reflected a Full Code status. During an interview, the Director of Nursing (DON) confirmed that the resident's code status should be Full Code, not DNR, highlighting the inaccuracy and lack of update in the resident's medical chart. This discrepancy was identified for one of two residents reviewed for advance directives.