Failure to Maintain Advance Directive in Medical Record
Penalty
Summary
The facility failed to maintain a copy of an executed advance directive in the medical record for one resident. According to the facility's policy, upon admission, if a resident has an advance directive, copies are to be made and placed in the resident's chart and communicated to staff. In this case, the resident was admitted and readmitted to the facility, and documentation showed the resident had the capacity to make decisions and had executed an advance directive, as indicated by both the Physician Orders for Life Sustaining Treatment (POLST) and an Advance Directive Acknowledgment form. Despite this documentation, there was no copy of the actual advance directive in the resident's medical record. This was confirmed during a medical record review and interview with the Assistant Director of Nursing (ADON), who verified that the advance directive should have been present in the chart to confirm the resident's wishes. The absence of the advance directive in the medical record constituted noncompliance with facility policy and federal requirements.
Plan Of Correction
1. The corrective action(s) accomplished for the residents found to have been affected by the deficient practice: Resident 51 was affected by this deficient practice. Immediately, the Social Services Director updated resident 51's advance directive record to reflect the current wishes of the resident. On 8/5/2025-8/8/2025, the Administrator in-serviced all Social Services and Licensed Nurses regarding advance directives, ensuring a copy of the resident's advance directive was placed in the resident's medical records and that it reflects the current wishes of the resident. 2. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 8/5/2025, medical records and social services audited all residents' advance directives to ensure they reflect current treatment plans and the wishes of the residents. If an advance directive is applicable, a copy was placed in the residents' medical records, and no other issues were noted. Social Services will review advance directives with residents during quarterly care plan meetings and as needed for any significant changes or if the responsible party or resident wishes to make changes to their advance directive. 3. Measures that will be put into place or systematic changes the facility will make to ensure that the deficient practice does not recur: DON and Social Services Director or designee will oversee this process. Social Services will review and discuss advance directives with all new admissions and re-admissions, and if a copy of the advance directive is available, it will be placed in the resident's medical records. Social Services will conduct quarterly audits of residents' advance directives and update the plan of care. Medical record audits will be performed on all new admissions and re-admissions to ensure a copy of the advance directive is in the medical record, if available. 4. Facility plans to monitor the effectiveness of the corrective actions and sustain compliance; integrate QA process: The DON and Social Services will monitor the effectiveness of the process. Any findings will be presented to the Monthly QA&A meeting. The Plan of Correction was presented at the Quality Assurance (QA&A) committee meeting on 08/14/2025. Ongoing findings from audits will be reported to the QAPI/QAA monthly meetings for at least three months. Corrective action completion date: 8/23/2025