Incomplete Advance Directive Documentation
Penalty
Summary
Facility staff failed to ensure that a resident's Advance Directive (AD) was fully completed. Upon review of the resident's paper chart, it was found that the AD lacked critical information, including the effective date of the designated health agent's power, a date on the resident's signature, and signatures and dates for two required witnesses. Additionally, the organ donation section of the AD was incomplete, and the witness signature and date fields were left blank. The deficiency was identified during a survey when the surveyor reviewed the resident's AD and brought the missing information to the attention of the facility's Administrator and Social Worker. Both acknowledged the incompleteness of the document. The incomplete AD was present in the resident's record at the time of the survey, and there was no indication that the required signatures and information had been obtained prior to the surveyor's review.