Failure to Accurately Document and Follow Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' medical records accurately reflected the status of advance directives and that discussions and written information regarding advance directives were properly documented. For one resident with moderate cognitive impairment and diagnoses including psychosis and depression, conflicting documentation was found: one note indicated an advance directive was on file, while a later note stated the resident did not have an advance directive and did not wish to formulate one. For another resident, who was cognitively intact and had diagnoses including COPD and paranoid schizophrenia, the records were inconsistent, with some assessments indicating an advance directive was on file and others stating there was none. The Advance Directive Acknowledgement Form also indicated the resident did not have an advance directive. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) confirmed that the SSD did not follow up to obtain or clarify the advance directive status for these residents, and acknowledged the importance of accurate documentation to ensure residents' wishes are honored. The facility's policy required that residents be provided with written information about advance directives upon admission and that copies of any advance directives be obtained and placed in the medical record, but this process was not consistently followed for the two residents in question.