Failure to Honor and Maintain Advance Healthcare Directives
Penalty
Summary
The facility failed to honor the advance healthcare directives for two residents, resulting in deficiencies related to the residents' rights to have their healthcare decisions respected. For one resident with severe cognitive impairment, the advance healthcare directive designated a specific family member as the healthcare agent and indicated a preference not to prolong life. However, the resident's medical record contained a POLST form that authorized CPR and artificial nutrition, was signed by a different family member, and incorrectly stated that no advance directive was available. Both the registered nurse and the social services director confirmed that the POLST form did not match the resident's documented wishes or the designated healthcare agent. For another resident who was cognitively intact, the facility failed to maintain a copy of the advance healthcare directive in the medical record. Although the resident's family provided the directive and documentation indicated it was received by the medical records department, the document was not uploaded or made readily retrievable in the electronic health record. Multiple staff interviews confirmed that the advance directive was not available in the resident's record, despite the POLST form indicating it had been reviewed. The facility's policy required that advance directives be obtained, maintained in a consistent and accessible section of the medical record, and that the resident's wishes be communicated to care staff and reflected in the plan of care. These requirements were not met for the two residents, resulting in the potential for their healthcare decisions and treatment preferences not being honored.