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 code status was accurately reflected in the electronic health record (EHR) in accordance with the resident's completed POLST form. Upon review, the resident's POLST form indicated a preference for Do Not Attempt Resuscitation, while the EHR incorrectly listed the resident as Full Code/Full Treatment. Staff interviews confirmed that social services are responsible for reviewing and ensuring the accuracy of the POLST upon admission, and facility policy requires that any decisions regarding a resident's choices be documented in the medical record and communicated to the care team. However, this process was not followed, resulting in a discrepancy between the resident's documented wishes and the information available to staff in the EHR.