Failure to Properly Document and Maintain Advance Directives
Penalty
Summary
The facility failed to ensure proper documentation and handling of advance directives for three residents. For one resident with multiple serious diagnoses, including palliative care and cancer, there was no signed copy of the advance directive in either the paper or electronic medical record, despite physician notes and care plans referencing DNR/DNI/DNH status. Staff interviews revealed that the signed form was missing, possibly due to chart thinning, and the nursing supervisor was responsible for ensuring its presence, but it could not be located. Another resident, admitted with multiple sclerosis and other conditions, had a signed advance directive form indicating DNR status, but the code status order was not transcribed into the electronic medical record. Both an LPN and an RN confirmed the absence of the code status order in the system, despite facility policy requiring entry within 24 hours of admission. The DON acknowledged that the missing order could have resulted in care inconsistent with the resident's wishes. A third resident with dementia and other conditions did not have a signed advance directive in the clinical record, and the care plan failed to include an advance directive plan of care. There were conflicting physician orders regarding code status, and staff interviews confirmed that the required documentation was not completed as per facility policy. The facility's policy mandates that advance directive information be prominently displayed in the medical record and that the RN supervisor ensures completion within 24 hours of admission, which was not followed in these cases.