Failure to Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to show documented evidence that advance directives were discussed and appropriately managed for three sampled residents. For one resident with acute respiratory failure, pneumonia, and cerebral infarction, there was no Advance Directive Acknowledgement Form in the medical chart, despite the resident having intact cognition and the capacity to make decisions. Both the RN and Social Services Designee confirmed the absence of documentation, and the Social Services Designee admitted that although the family was spoken to, there was no proof that information about advance directives was provided. Another resident, admitted with multiple diagnoses including neuropathy and diabetes, had signed an Advance Directive Acknowledgement Form indicating the existence of a living will. However, the actual living will was not present in the resident's chart, and there was no documentation regarding its contents. The responsible Social Services staff member acknowledged forgetting to follow up and obtain a copy of the living will, which was necessary for staff to be aware of and honor the resident's wishes when the resident could no longer make decisions. A third resident, with diagnoses including congestive heart failure and urinary retention, had expressed interest in formulating an advance directive and requested assistance from the Ombudsman. Although the facility faxed a request to the Ombudsman, there was no documented follow-up or evidence in the medical record that assistance was provided or that the process was completed. The Social Services staff and Director both acknowledged that the lack of follow-up and documentation could result in delays or failure to honor the resident's wishes, as the process had been pending for over three months.