Failure to Maintain Advance Directive Documentation for Two Residents
Penalty
Summary
The facility failed to maintain proper documentation of advance directive information for two residents. For one resident with dementia, diabetes, and chronic kidney disease, the facility's records indicated that an advance directive had been executed, but only a general power of attorney document related to financial decisions was available in the electronic medical record. The facility was unable to provide documentation of a medical power of attorney for this resident. For another resident with diabetes, cerebral infarction, and interstitial pulmonary disease, the records also indicated that an advance directive had been executed, but there was no documentation of the advance directive in the resident's electronic medical record. A notation in the records stated that the family never provided the document, and when requested, the facility could not produce a copy. Interviews with facility staff, including the Admissions Coordinator, Social Service Director, Director of Nursing, and Administrator, confirmed that advance directives were addressed during the admission process and followed up on if not initially provided. However, despite these procedures, the facility did not have the required documentation for the two residents, and staff were unable to specify a clear timeframe for obtaining missing advance directive paperwork. The lack of documentation meant the facility did not have current information on the residents' wishes or designated responsible parties for medical decisions.