Failure to Obtain and Maintain Resident Advance Directive
Penalty
Summary
The facility failed to obtain and maintain a copy of an advance directive for one resident who was identified as having such a document upon admission. The resident, who had moderate cognitive impairment but was assessed as having the capacity to make decisions, indicated the existence of an advance directive on an acknowledgement form. The facility's policy required that a copy of the advance directive be requested and maintained in the resident's medical record. Documentation showed that the Social Service department requested the document and left a voicemail for the resident's sister, but there was no evidence of further follow-up or that the document was ever obtained. Interviews with Social Service staff and review of the medical record confirmed that the required copy of the advance directive was not available in the resident's file. The Social Service department acknowledged that, according to facility policy, follow-up attempts should have been made and documented if the initial request was unsuccessful. The absence of the advance directive in the medical record was verified by both the Social Service staff and the facility's Administrator and DON during the survey.