Missing Power of Attorney Documentation in Resident Record
Penalty
No penalty information released
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Summary
The facility failed to maintain a complete medical record for one resident by not having the Power of Attorney (POA) documentation on file. During a review of the resident's clinical record, it was noted in the electronic profile that the resident had a POA, but the actual POA paperwork could not be located. In an interview, the Director of Nursing confirmed that the POA document was not available in the resident's file. This deficiency was identified through record review and staff interview, with the surveyor unable to find the required documentation to support the resident's advance directive status as indicated in the clinical record.