Failure to Incorporate Advanced Directives into Care Plan
Penalty
Summary
The facility failed to develop a plan of care addressing advanced directives for one resident reviewed for advanced directives. According to the facility's own guidelines, staff are required to identify, clarify, and review existing care instructions during the quarterly Resident Assessment Instrument (RAI) process and with any significant changes in condition. These guidelines also require that any changes to a resident's advanced directives be documented, included in the resident's care plan, and communicated to staff. However, for one resident, although a completed and signed POLST form indicated a Do Not Resuscitate (DNR) order and a preference for comfort-focused treatment, there was no corresponding plan of care addressing these advanced directives in the resident's current care plan. During an interview, the Care Plan Coordinator confirmed that the resident did not have a current care plan addressing advanced directives. This omission was identified through record review and staff interview, demonstrating that the facility did not follow its own procedures for ensuring that residents' advanced directives are incorporated into their care plans and communicated to staff.