Failure to Obtain and Document Advance Directive for Resident
Penalty
Summary
The facility failed to obtain and document an advance directive (AD) for one resident, despite multiple indications in the resident's records that an AD was either in place or should have been reviewed. The electronic health record (EHR) for the resident, who was admitted with diagnoses including heart failure and diabetes, did not show an AD on file. The resident believed that an AD had been completed and that the facility had the paperwork. Care plan documentation referenced an AD and indicated that education was provided and that staff would review healthcare directives with the resident at least quarterly. However, upon review, the admission record did not show an AD, and the Social Services Director confirmed that no AD was in place at the time. The Social Services Director also acknowledged that a discussion about the AD should have been documented upon the resident's readmission, but this did not occur. The Administrator stated that ADs were to be reviewed upon admission and quarterly, and documented in the EHR, but was unable to locate the AD for this resident, confirming that documentation did not meet expectations.