Failure to Document and Acknowledge Advance Directives for Residents
Penalty
Summary
The facility failed to ensure that two of three sampled residents had proper documentation and acknowledgement of their advance directives. For both residents, although physician orders and care plans indicated a full code status, there was no electronic or physical evidence in their clinical records of a signed advance directive or documentation of a discussion with the residents or their representatives regarding their code status. One resident had a BIMS score indicating no cognitive impairment, yet there was still no record of an advance directive discussion or signed document. Interviews with facility staff, including an RN, CNA, LPN, and the DON, confirmed that the facility's process required completion and storage of advance directive paperwork both physically and in the EMR. Staff acknowledged that the absence of this documentation could result in residents' wishes not being honored. The DON was unable to locate advance directive documentation for the two residents in question, and policy review confirmed that the facility was required to provide written information and maintain a copy of the advance directive in the medical record.