Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to maintain accurate and current copies of advance directives in the clinical records for three out of four sampled residents. During record reviews and interviews, it was found that the medical charts for these residents did not contain their advance directives, despite facility policy requiring such documentation. Licensed vocational nursing staff confirmed the absence of these documents in the residents' charts, acknowledging that this could lead to confusion regarding the residents' wishes in the event of a medical emergency. The residents involved had varying medical conditions, including muscle weakness, rheumatoid arthritis, hypertension, atrial fibrillation, and diabetes, with cognitive statuses ranging from intact to moderately impaired. The Minimum Data Set assessments indicated differing levels of assistance required for activities of daily living. The facility's policy states that residents have the right to formulate advance directives and that these should be included in their records, but this was not followed for the residents in question.