Failure to Maintain Complete Medical Records for Advance Directives
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 maintain correct and complete medical records for two of thirty residents reviewed, as required by accepted professional standards. Specifically, on 06/17/25, advance directives were not found in the electronic medical charts for two residents. This was confirmed by the Interim Administrator, who acknowledged that the advance directives were missing from the medical records for these residents. The facility's own policy requires that patients' resuscitation wishes be documented in the medical record, but this documentation was not present for the affected residents.