Failure to Maintain and Document Advance Directive in Resident Record
Penalty
Summary
The facility failed to obtain and/or maintain a copy of an executed advance directive in the medical record for a resident who was admitted without capacity to make medical decisions. Upon admission, documentation showed that the resident had executed an advance directive, and the facility's policy required that copies of such documents be placed in the resident's chart and communicated to staff. However, a review of the resident's medical record did not show a copy of the advance directive, nor was there evidence of any follow-up attempts to obtain or document the advance directive. Further review revealed that the Physician Orders for Life-Sustaining Treatment (POLST) form for the resident had the section for advance directive information left blank. Interviews with facility staff indicated that prior to a departmental change, the admissions team handled advance directive forms, but the Social Services department, now responsible, did not have documentation or records of the resident's advance directive or any follow-up. The Administrator, Director of Social Services, and Director of Nursing acknowledged these findings during the survey.
Plan Of Correction
F - 578 Request/Refuse/Dscntnue Trmnt; Fornite Adv Dir Corrective Action Initiated For Resident/s Resident 52's advance directive status was immediately reviewed on 6/20/25 by SSD. Social Services obtained a copy of the advance directive and placed it into the resident's medical record. Resident 52's POLST form was reviewed and updated to accurately reflect the advance directive information on 6/23. How Potential Other Residents Were Identified and Corrective Action Taken Other residents are at risk for this noted practice. Starting on 6/23 through 7/7/25, the Social Services Director (SSD) initiated an audit of all current resident medical records to ensure advance directives were accurately documented, present in charts, and consistent with resident or representative decisions. Measures/Systemic Changes Initiated to Prevent Future Recurrence On 6/25/25, all admissions and Social Services staff were re-educated by the DON regarding facility policy and procedures for obtaining, maintaining, and documenting advance directives upon admission, including immediate follow-up processes. A standardized admission checklist was implemented to verify the presence and accurate documentation of advance directives during each admission. Findings will be reported at daily stand-up for follow-up. Social Services will check new admits for follow-up documentation and the maintenance of advance directive copies on a weekly basis. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The POC is integrated into the QA system. The SSD will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/7/25 A standardized admission checklist was implemented to verify the presence and accurate documentation of advance directives during each admission. Findings will be reported at daily stand-up for follow-up. Social Services will check new admits for follow-up documentation and the maintenance of advance directive copies on a weekly basis. Monitoring Plans to Ensure Solutions are Achieved and Integrated into QA System The POC is integrated into the QA system. The SSD will provide a summary trend analysis of the findings to the facility's monthly QAPI Committee for 3 months or until such time consistent substantial compliance has been achieved as determined by the committee. Date of compliance: 7/7/25