Failure to Complete and Maintain Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that Advance Directives (AD) and AD Acknowledgement Forms were properly completed and included in the medical records for two residents. For one resident with end stage renal disease, hydronephrosis, and dependence on hemodialysis, there was no copy of an AD or AD acknowledgement form in either the paper chart or electronic medical record. The Social Services Director confirmed that these documents should be updated and accessible with each admission or readmission to inform staff of the resident's wishes and preferences. The Director of Nursing also stated that all residents should have updated AD and ADA forms in their records, completed and signed upon admission or readmission, to ensure residents and their representatives are informed of their rights regarding medical treatment and advance directives. Another resident, admitted with type 2 diabetes mellitus and unspecified dementia, had an AD Acknowledgement Form that was not filled out completely. The Social Worker and Director of Nursing both confirmed that the form was incomplete and emphasized the importance of having it fully and accurately completed to reflect the resident's medical wishes. The facility's policy and procedure required inquiry about advance directives and provision of written information about the right to refuse or accept treatment prior to or upon admission, but this was not followed for the sampled residents.