Failure to Implement Advance Directive Policy for Resident
Penalty
Summary
The facility failed to implement its policy regarding Advance Directives (AD) for one resident. Upon admission, the facility's policy required staff to obtain a copy of the resident's AD and include it in the medical record, or provide information about ADs if the resident did not have one. Record review showed that the resident was admitted with multiple diagnoses, including cerebral palsy, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition. Although the resident had signed a Physician Orders for Life-Sustaining Treatment (POLST) form and stated he had an AD, there was no AD or Power of Attorney (POA) document found in his facility records. Interviews with facility staff, including Medical Records, Social Services, and the Director of Nursing, confirmed that the facility did not follow up with the acute care hospital to obtain a copy of the resident's AD, despite documentation indicating the resident had one at the time of admission. Staff acknowledged that the resident had the mental capacity to make his wishes known and that the AD should have been present in the chart, but it was not. The facility did not adhere to its own policy for securing and maintaining advance directive documentation for this resident.