Failure to Obtain and Document Advance Directives Upon Admission
Penalty
Summary
The facility failed to obtain and document information related to advance directives and health care decisions for one resident who was admitted following surgery. Upon admission, the resident did not have an Advance Directive or a POLST (Physician Orders for Life-Sustaining Treatment), as indicated by the Health Care Admission Questionnaire. Although facility policy required that such documents be maintained as hard copies and made available for emergencies, staff did not include a POLST or Advance Directive in the admission paperwork for the physician to review with the resident. Staff acknowledged this omission during interviews. Further interviews with the resident and a family member confirmed that neither a POLST nor an Advance Directive was completed with the physician after admission, and that the facility did not offer these documents, despite the resident being offered an Advance Directive at the hospital prior to admission. Facility leadership stated that while a questionnaire was used to determine if residents had these documents, the Advance Directive was not included in the admission packet, and residents would need to request one if desired. This failure to provide and discuss advance directive options resulted in the resident not having their health care decisions documented as required.