Failure to Obtain and Document Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to ensure that advance directives (ADs), such as living wills or Durable Power of Attorney (DPOA) for health care, were obtained and completed for three residents. For one resident with minimal cognitive impairment, the admission documentation indicated uncertainty about having an AD, and there was no evidence in the electronic health record (EHR) or care plan that assistance was provided to formulate one. Another resident, who was alert and oriented, also had no AD or DPOA documented, and no follow-up or assistance was recorded in the EHR or care plan. For a third resident with moderate cognitive impairment, the admission packet noted a DPOA, but no copy was found in the EHR, and care conference notes did not mention the AD or DPOA. Interviews with staff, including the Medical Records staff, Assistant Director of Nursing Services, and Director of Nursing, confirmed the absence of required AD documentation and lack of follow-up to assist residents in formulating ADs. Staff described the expected process for obtaining and uploading ADs, as well as social services' responsibility to follow up during initial care conferences, but could not explain why documentation was missing. This deficiency was noted as a repeat issue from a previous survey.