Failure to Maintain Advanced Directive and POA Documentation in EMR
Penalty
Summary
The facility failed to maintain and safeguard resident-identifiable information and medical records in accordance with accepted professional standards for one resident. During the resident's admission, although a DNR order was entered and signed in the electronic medical record (EMR), there was no evidence that the resident's completed DMOST (Delaware Medical Orders for Scope of Treatment) form or financial power of attorney (POA) documentation was present in the EMR. Staff interviews confirmed that the advanced directive and POA documents were not obtained from the hospital or assisted living facility at admission, and the business office manager stated that a copy of the POA was never received, despite being informed that the financial POA was handling billing and applying for guardianship. The resident had a history of dementia and moderate cognitive impairment at the time of admission.