Failure to Maintain Advance Directive Documentation in Resident Record
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive (AD) and AD Acknowledgement Form were present in the medical record for one of three sampled residents. Upon review of the resident's admission record, it was found that the resident, who had a history of malignant neoplasm of the lung, pneumonia, and chronic kidney disease, did not have a copy of the AD or the AD acknowledgement form in either the paper chart or the electronic medical record. The resident's Minimum Data Set indicated moderately impaired cognition and a high level of dependence on staff for daily activities. Interviews with the RN Supervisor and the DON confirmed that the AD and AD acknowledgement form should be updated and included in the resident's chart with each admission or readmission. The facility's policy also required that residents be provided with information about their rights regarding medical treatment and advance directives upon admission, and that this information be prominently displayed in the medical record. The absence of these documents in the resident's record was verified during the survey process.