Failure to Obtain and Document Advance Health Care Directives
Penalty
Summary
The facility failed to obtain and document Advance Health Care Directives (AHCD) for two residents. For one resident, the electronic health record showed a note indicating that Social Services would follow up with the hospice provider regarding the AHCD, but there was no documentation of any follow-up attempts. The Social Services Coordinator confirmed that no further action was taken to obtain the AHCD and acknowledged that alternative contacts, such as the visiting nurse from the hospice provider, were not pursued. For the second resident, no AHCD was found in the electronic health record, and the Director of Nursing was unable to provide documentation. A late entry was made by the Social Worker, documenting a prior discussion in which the resident refused an AHCD, but this was only entered after a reminder from leadership. The resident recalled an initial discussion about the AHCD upon admission but did not remember any recent conversations. Both the Social Worker and Social Services Coordinator agreed that AHCD documentation should be completed quarterly and entered promptly into the electronic health record, but this was not done in a timely manner.