Failure to Complete Advance Directive Acknowledgement on Admission
Penalty
Summary
The facility failed to implement its policy and procedure regarding advance directives for one resident. Upon admission, the required Advance Directive Acknowledgement (ADA) form for this resident was not properly completed. Specifically, the ADA form did not indicate whether the resident had executed an advance directive, was missing a date for the resident's signature, and lacked the facility's signature. The facility's policy requires that ADA forms be completed within seven days of admission by the Social Services Director or designee. The resident involved had diagnoses including chronic obstructive pulmonary disease (COPD) and diabetes mellitus, and was assessed as having intact cognition and requiring some assistance with activities of daily living. During an interview, the Social Service Director confirmed that the ADA form was incomplete and stated that the resident had not executed an advance directive. The incomplete documentation meant that staff would not have clear information about the resident's care and treatment preferences in the event of an emergency.