Inaccurate Documentation of Advance Directive Status
Penalty
Summary
The facility failed to ensure the accuracy of a medical record for one resident when the Advance Directive Acknowledgement form incorrectly indicated that the resident had an Advance Directive, despite no such document existing. The resident in question was admitted with diagnoses including pneumonia, bipolar disorder, and schizophrenia, and was noted to be deaf and non-speaking. The Minimum Data Set assessment indicated that no Advance Directive was completed for this resident. Additionally, a letter from the regional center clarified that the resident was not capable of providing informed consent, had no court-appointed conservator or guardian, and that a regional center designee would provide consent for medical treatments. During interviews, the responsible party from the regional center confirmed there was no Advance Directive for the resident, and the Social Services Director acknowledged that the Advance Directive Acknowledgement form was incorrect. The facility's policy required staff to inquire about the existence of an Advance Directive upon admission and to document its presence or offer the opportunity to create one if it did not exist. However, the documentation in the resident's medical record inaccurately reflected the existence of an Advance Directive, resulting in a deficiency related to the maintenance of accurate medical records.