Failure to Document Advance Directive Discussions
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to document that advance directives were discussed with the residents and/or their responsible parties. Specifically, for three out of 25 sampled residents, there was no documentation indicating that advance directives were addressed. One resident, who was cognitively intact and admitted with muscle wasting and atrophy, had no record of an advance directive discussion in their file, as shown by the absence of such documentation on their POLST form. Two other residents, both with severe cognitive impairment and diagnoses including depression, adult failure to thrive, and dementia, also lacked documentation of advance directive discussions or availability in their medical records. During interviews and record reviews, the Social Service Director Assistant confirmed that there was no evidence in the records for these residents that advance directives had been discussed with them or their responsible parties. The Director of Nursing was not aware of the facility's policy regarding advance directives. The facility's policy requires inquiry about advance directives upon admission and annual review, with documentation to be prominently displayed in the medical record, but this was not followed for the affected residents.