Failure to Obtain and Maintain Advance Directive and POA Documentation
Penalty
Summary
The facility failed to ensure that an advance directive and Power of Attorney (POA) documentation were properly formulated and maintained in the medical record for a resident with severely impaired decision-making skills. Upon admission, the resident was identified as having both short-term and long-term memory problems and was assessed as severely impaired in decision-making. The admission record indicated the resident was a full code status, but there was no documentation of a designated POA or primary decision-maker for care in the medical record. The social assessment form, completed by the resident's spouse, noted that a POA document existed and would be provided to the facility, but there was no evidence that the facility followed up to obtain this documentation until prompted during the survey. Interviews with facility staff confirmed that the POA documentation was not present in the resident's record and that no further contact had been made with the spouse to secure the necessary documents prior to the survey. The spouse confirmed that the existence of the POA and advance directive had been discussed at admission, but the facility did not obtain or file the documentation as required by their policy. The facility's policy states that on admission, staff must determine if an advance directive exists and, if so, ensure copies are placed in the chart and communicated to staff, which was not done in this case.