Failure to Obtain and Document Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to obtain and maintain documentation of advance directives and health care decisions for three residents with significant medical conditions, including chronic inflammatory demyelinating polyneuritis, sepsis with metabolic encephalopathy, and stroke. For each resident, care plans and care conference notes indicated that advance directives were in effect or had been reviewed, but no actual advance directive documents were found in the clinical records. Interviews with the residents revealed that they either had not completed an advance directive, were unsure if one was completed, or believed the facility did not have a copy. Staff interviews confirmed that there was no advance directive on file for any of the three residents, and the Social Services Coordinator acknowledged that follow-up to obtain or confirm these documents had not occurred. In one case, documentation indicated that a power of attorney (POA) was to be contacted, but there was no evidence this was done. The Executive Director stated that blank advance directive forms were provided at admission, but follow-up and documentation were not consistently completed.