Failure to Obtain and File Advance Healthcare Directive
Penalty
Summary
The facility failed to obtain and include a copy of an advance healthcare directive in the medical record for one resident who was reviewed for advance directives. According to the facility's policy, staff are required to obtain a copy of the advance directive and ensure it is placed in the resident's health record. During the review, it was found that although the resident's POLST form indicated that an advance directive was available and had been reviewed, there was no documented evidence in the medical record that the actual advance healthcare directive had been obtained or filed. The resident in question had a severe cognitive impairment and had a California General Durable Power of Attorney for financial matters documented in the record, but not the advance healthcare directive. Interviews with the RN, Social Services Director, and Social Services Resource staff confirmed that the social services department was responsible for following up on advance directives. They verified that while the POLST referenced the existence of an advance directive, the document itself was not present in the resident's medical record.