Failure to Maintain Resident's Advance Directive in Clinical Record
Penalty
Summary
Facility staff failed to maintain a current copy of a resident's advance directive in the active clinical record, despite documentation indicating that the resident had executed such a directive. The resident, who had diagnoses including normal pressure hydrocephalus, type 2 diabetes mellitus, and major depressive disorder, was assessed as having intact cognition and the capacity to make decisions. During record review, it was found that while the Advance Directive Acknowledgement Form indicated the existence of an advance directive, the actual document was not present in the resident's chart. Interviews with the Director of Social Services and the Director of Nursing confirmed that the advance directive should have been kept in the resident's active chart to guide staff in honoring the resident's wishes. The facility's policy also required that a copy of any executed advance directive be maintained in the resident's medical record and be readily retrievable by staff. The absence of the advance directive in the clinical record constituted a failure to ensure the resident's wishes regarding medical treatment were accessible to facility staff.