Failure to Maintain Advance Directive in Medical Record
Penalty
Summary
The facility failed to maintain a copy of an advance directive in the medical record for one resident reviewed for advance directives. According to the facility's policy and procedure, the Social Service Director (SSD) or designee is responsible for inquiring about the existence of any written advance directives upon admission and ensuring that information about the advance directive is prominently displayed in the medical record. For the resident in question, medical record review showed that although the family member stated an advance directive existed and would provide a copy, no such document was found in the resident's medical record or uploaded in the electronic medical record (EMR). Further review of the resident's records, including the POLST and H&P examination, did not reveal the presence of the advance directive. During an interview, the SSD confirmed that the advance directive was not present in the medical record and acknowledged that it should have been obtained and maintained. The Director of Nursing (DON) was informed and acknowledged these findings.