Incomplete Advance Directives Documentation in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident. Specifically, the Advance Directives Acknowledgement (ADA) form for a resident was found to be incomplete, missing the resident's initials. The Admission Coordinator, who was responsible for completing the ADA form upon admission, confirmed during an interview and record review that the form was not properly filled out. The ADA form is a legal document included in the resident's medical record and is intended to reflect the resident's medical needs and wishes. The resident involved had a history of major depressive disorder, gastrostomy, and anemia, and was dependent on staff for activities of daily living, though their cognitive skills were intact. The facility's policy required that medical records be complete and accurate, but this was not followed in this instance, resulting in an incomplete legal document within the resident's file.