Inaccurate Documentation of Health Care Proxy Activation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident by not correctly documenting the activation status of the resident's health care proxy (HCP). The resident, who was admitted with diagnoses including left calf hematoma evacuation, wound debridement, and atrial fibrillation, was assessed as moderately cognitively impaired with a BIMS score of eight out of 15. The facility's records, including the Minimum Data Set (MDS), physician's orders, and care plan, indicated that the resident's HCP was activated. However, review of the outside hospital's discharge summary showed that while the resident had signed advanced directives and a HCP document, there was no indication that the HCP had been invoked at the hospital. Further review of physician and nurse practitioner progress notes consistently documented that the HCP was not activated. During an interview, a unit manager acknowledged that the order indicating HCP activation may have been entered in error. This inconsistency in documentation resulted in the resident's medical record failing to accurately reflect the true status of the HCP activation, contrary to the facility's policy and accepted professional standards.