Failure to Obtain and Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to obtain and/or maintain Advance Directives (AD) for two of twenty sampled residents. For one resident who was severely cognitively impaired, there was no documentation in the care plan or electronic health record (EHR) regarding the existence of an AD, nor evidence that information or assistance was provided to develop one. The social history assessment also did not indicate the presence of a responsible party or legal guardian, and staff confirmed that no outreach was made to the resident's family regarding guardianship or ADs. For another resident who was alert and oriented, the care plan documented that the resident did not wish to execute an AD at the time and that AD information should be offered quarterly and as needed. However, there was no documentation in the EHR that AD information was reviewed or offered on a quarterly basis or as needed. Staff interviews confirmed the lack of documentation and acknowledged that the facility's expectation was to review and offer AD information upon admission and quarterly.