Failure to Complete and Document Advance Directive Choices for Multiple Residents
Penalty
Summary
The facility failed to ensure that advance directive choices were properly completed and documented for multiple residents. For one resident with schizoaffective disorder and borderline intellectual functioning, the care plan did not include an advance directive, and there was no signed consent from the conservator, despite a physician order indicating full code status. The Director of Nursing Services (DNS) confirmed that the required consent should have been obtained and filed at admission, but it was missing from both the paper and electronic records. Another resident with diabetes, legal blindness, anxiety, and bipolar disorder had an unsigned advance directive in the chart, coded as Do Not Intubate/Do Not Resuscitate (DNI/DNR), and no physician order could be written without a completed and signed form. Staff interviews revealed that the conservator had not completed the necessary paperwork, and attempts to contact the conservator had been unsuccessful. The facility's protocol required the advanced directive to be signed on admission, but documentation of efforts to obtain the signature was lacking, and the resident was not properly included in a facility-wide audit of advance directive documentation. A third resident with cauda equina syndrome, COPD, and morbid obesity was identified as a full code in the care plan and social services notes, but the advance directive was missing both the resident's and physician's signatures. The admission nurse was responsible for ensuring completion of the advance directive, with social services reviewing the documentation at the 72-hour post-admission meeting. However, the required signatures were not obtained, and the social worker could not explain why the documentation was incomplete. Facility policy required determination and documentation of advance directive status on admission, but this was not consistently followed.