Advance Directive Not Available in EHR or Physical Form
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 current advance directive, specifically the New Mexico Orders for Scope and Treatment (MOST), was available in the resident's Electronic Health Record (EHR) or in physical form for staff access. Record reviews showed that the resident was admitted to the facility and had a documented Do Not Resuscitate (DNR) order in both the physician orders and care plan. However, the actual advance directive form was not present in the EHR or available physically. During an interview, the Director of Nursing confirmed that the MOST form was missing from both the EHR and physical records, despite the resident's DNR status being documented elsewhere.