Failure to Maintain Advance Directives in Resident Medical Charts
Penalty
Summary
The facility failed to ensure that advance directives were present in the medical charts for two of four sampled residents, as required by its own policy. For one resident with end stage renal disease and atherosclerotic heart disease, the admission record and MDS indicated moderate cognitive impairment and significant assistance needs. Although the POLST form referenced an advance directive, no such document was found in the resident's medical chart during review. Social Services staff confirmed that the advance directive was not available in the chart until after the review, acknowledging that it should have been accessible to licensed staff. For another resident with diabetes mellitus and asthma, the admission record and MDS showed intact cognitive skills but substantial assistance required for daily activities. The resident's records included an Advance Directives Acknowledgement form indicating an executed advance directive, but the actual document was not present in the medical chart. The DON confirmed the absence of the advance directive in the chart and stated that it should have been included to ensure the facility could honor the resident's wishes and identify decision-makers in emergencies. Facility policy required that information about advance directives be displayed prominently in the medical record, which was not followed in these cases.