Failure to Ensure Proper Completion and Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that residents' rights regarding advance directives and medical decision-making were properly honored and documented for two residents. For one resident, the out-of-hospital do-not-resuscitate (OOH-DNR) order was not properly completed, lacking a dated physician signature and the required two witness signatures or notarization. Additionally, this resident did not have a documented medical power of attorney (MPOA) form in the medical record, and the only available statutory durable power of attorney (SDPOA) form explicitly stated it did not authorize medical decision-making. The admission agreement also failed to specify a designated MPOA, and there was confusion among family members and staff regarding who was authorized to make medical decisions for the resident. For the second resident, the OOH-DNR order was also incomplete, missing the required second signatures from witnesses and a guardian/agent/proxy/relative. Both residents had significant cognitive impairments, as documented in their medical records and care plans, which further emphasized the importance of having clear and valid advance directive documentation. Staff interviews revealed inconsistent understanding and processes regarding the review and validation of advance directives, with some staff relying on face sheets or posted lists rather than verifying the validity of legal documents. Facility policy required adherence to residents' rights to formulate advance directives and mandated regular audits of code status documentation. However, the review of records and staff interviews indicated that these policies were not consistently followed, resulting in incomplete or invalid advance directive documentation. The lack of proper documentation and clarity regarding medical decision-makers could lead to confusion and the potential for residents' wishes to be disregarded.