Failure to Ensure Proper Discussion and Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's health care advance directives were properly discussed and documented. A review of the medical record for a resident with adequate decision-making capacity showed that staff had documented the presence of an advance directive during admission and in a subsequent social service assessment. However, upon further review, no advance directive was found in either the electronic medical record or the paper chart. Instead, only a durable power of attorney document, which did not address health care decisions, was located in the record. Interviews with the Social Service Designee (SSD) revealed that there was confusion regarding the correct documentation, and the SSD acknowledged that the document on file was not related to health care. There was also no documentation indicating that the family was informed about the missing or incorrect paperwork. The deficiency was identified when surveyors noted the discrepancy between the documentation stating an advance directive was on file and the actual absence of such a document in the resident's records.