Failure to Maintain Advance Directives in Resident Medical Records
Penalty
Summary
The facility failed to ensure that copies of residents' Advance Directives (ADs) were maintained in their medical charts and were easily retrievable, as required by facility policy. For two residents, documentation in the Physician Order for Life-Sustaining Treatment (POLST) indicated the existence of an AD, but during concurrent interviews and record reviews, the Medical Records Assistant was unable to locate physical copies of these ADs in the residents' medical records. The Director of Nursing confirmed that a copy of the AD should be present in the physical chart for staff access. Both residents involved had significant medical histories, including conditions such as congestive heart failure, dementia, diabetes, Parkinson's disease, and epilepsy. Assessments indicated that these residents required varying levels of assistance with activities of daily living and were generally able to understand and communicate with others. The facility's policy, last reviewed in June 2025, specified that copies of executed advance directives must be obtained and maintained in a designated section of the medical record, but this was not followed in these cases.