Failure to Maintain Accessible Advance Directives and POLST in Resident Record
Penalty
Summary
The facility failed to ensure that the Advance Directives Acknowledgement Form and the Physician Orders for Life-Sustaining Treatment (POLST) were obtained and readily accessible in the hard copy medical record for one resident. During a review of the resident's admission record, it was noted that the resident had diagnoses including bipolar disorder and paranoid schizophrenia, with documentation indicating fluctuating capacity to understand and make decisions. The resident's Minimum Data Set assessment also showed severely impaired cognition. Despite these factors, both the Social Services Designee and the Registered Nurse Supervisor confirmed during interviews and record reviews that the advance directive acknowledgement form and POLST were not present in the resident's medical record. The Director of Nursing also acknowledged that these documents must be readily accessible in the resident’s hard copy medical record to guide licensed nurses in providing care according to the resident’s wishes during emergencies. The facility’s policy and procedures require that written information about advance directives be provided upon admission, but this was not reflected in the resident’s record. The absence of these critical documents was directly observed and confirmed by multiple staff members during the survey.