Failure to Obtain and Review Advanced Directives and Guardianship Documentation
Penalty
Summary
The facility failed to obtain and maintain appropriate legal documentation regarding advanced directives (AD) and guardianship for two residents. For one resident with a history of dementia, bipolar disorder, and psychotic disorder, the electronic health record (EHR) did not contain documentation of a durable power of attorney (DPOA) for healthcare, despite a physician's statement from several years prior indicating the resident lacked capacity to make their own healthcare decisions. The resident was unable to confirm if the facility had the necessary legal paperwork, and staff interviews confirmed that the AD was not present in the EHR and had not been reviewed as required during care conferences or the previous quarter. For another resident with a history of high blood pressure and stroke, there was no documentation of an AD for healthcare in the EHR, and care conference reports repeatedly indicated that no AD or DPOA was in place, with relevant sections left blank or marked as not applicable. The resident stated they did not have an AD, and staff were unable to locate any such documentation or explain the lack of follow-up. The facility's failure to obtain, document, and periodically review these legal documents did not meet expectations and was confirmed by both the Social Services Director and the Administrator.