Failure to Obtain Advance Directive Upon Admission
Penalty
Summary
The facility failed to obtain a copy of a resident's Advance Directive (AD) upon admission, as required by facility policy. The resident was admitted with diagnoses including cerebral infarction and metabolic encephalopathy, and their cognitive skills were noted to be moderately impaired. Documentation indicated that the resident had an AD and needed to bring a copy, but the facility did not secure this document at the time of admission. Both the Social Service Director and the Director of Nursing confirmed during interviews that the AD was not obtained, despite acknowledging the importance of having this information available in the resident's health record. A review of the facility's policy revealed that staff are required to provide written information about advance directives to residents or their representatives and to obtain and file a copy of the AD in the resident's health record when available. In this case, the required documentation was not collected or placed in the record, resulting in a deficiency related to honoring the resident's right to have their healthcare wishes known and respected.