Failure to Ensure Accurate and Complete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that residents and/or their responsible parties were properly informed about their rights to formulate an Advance Directive (AD) and that documentation regarding ADs and Physician Orders for Life-Sustaining Treatment (POLST) was accurate and complete. In several cases, forms were either incomplete, not signed by the appropriate party, or not filled out at all. For example, one resident's POLST and AD Acknowledgement Form were signed by an individual who was not the documented responsible party, and the facility's records did not clarify the authority of the signer. In another instance, a resident's AD Acknowledgement Form was missed entirely during the admission process, which was later acknowledged by the Social Services Designee (SSD) as an oversight. Multiple residents with varying degrees of cognitive impairment and medical complexity were affected by these documentation failures. Some residents were cognitively intact and able to make their own medical decisions, while others were severely or moderately impaired and dependent on staff or responsible parties for decision-making. In several cases, the AD Acknowledgement Forms were not fully completed, with key sections left unchecked regarding whether the resident had executed an AD. Additionally, some POLST forms were not signed and dated by the resident, and in at least one case, the responsible party was incorrectly identified and allowed to sign critical documents. Interviews with facility staff, including the SSD, RNs, LVNs, and the Director of Nursing (DON), confirmed that these omissions and inaccuracies were due to lapses in the admission and documentation process. Staff acknowledged that the forms should be completed upon admission and that incomplete or missing documentation could result in staff not knowing the resident's wishes in emergency situations. The facility's own policy required inquiry about advance directives prior to or upon admission, but this was not consistently followed, as evidenced by the incomplete or missing forms for several residents.
Plan Of Correction
F578: Request/Refuse/Discontinue Treatment; Formulate Adv Dir CORRECTIVE ACTION From 3/21/25 to 3/25/25, the SSD and SSA added an accurately completed copy of the Advance Directive Acknowledgement Form (ADAF) and Physician Orders for Life-Sustaining Treatment (POLST) to the medical records of Residents 5, 6, 11, 35, 37, 41, and 75 signed by residents or appropriate Responsible Party depending on residents' capacity to make decisions. On 3/21/25 the DON conducted an in-service for Licensed Staff, SSD, Medical Records regarding the importance of completing the Advance Directive Acknowledgement Form and Physician Orders for Life-Sustaining Treatment (POLST) accurately signed by resident or appropriate Responsible Party depending on residents' capacity to make decisions upon admission. OTHER RESIDENTS AFFECTED IDENTIFICATION From 3/21/25 to 3/25/25, the SSD and SSA conducted a comprehensive review of all active residents to ensure they had been provided with information on formulating an Advance Directive and that any completed POLST forms were accurate. Upon completion of the review, no additional residents were found to be affected by this deficient practice. MEASURES AND SYSTEMIC CHANGES Upon admission, new residents will be provided with information on how to formulate an Advance Directive. If an Advance Directive is already in place, a copy will be obtained from the resident or their representative and promptly placed in the resident's medical record upon receipt. The SSD/SSA, in coordination with the Medical Records (MR) department, will ensure that all residents receive information on Advance Directives and that a copy is obtained from the resident or their representative, if applicable, and placed in their medical record. The SSD/SSA, in coordination with the Medical Records Director (MRD), will ensure that the Advance Directive Acknowledgment Form (ADAF) is completed and that residents' POLST forms are accurately completed upon admission. MONITORING PERFORMANCE The Social Service Director (SSD) and Administrator will ensure that the above process is consistently maintained. The SSD or designee will report any trends or issues related to providing residents with information on creating an Advance Directive and completing a POLST, as well as confirming whether a copy of the ADAF and POLST is included in the resident's medical record. These reports will be submitted to the QAA Committee monthly for a period of three months or until compliance is achieved, for further review and any additional recommendations.