Failure to Document and Follow Up on Advanced Directives, Resident Fears, and Unauthorized Medication Administration
Penalty
Summary
The facility failed to ensure adequate care, follow-up, and documentation regarding advanced directives, resident-reported fear of certain family members, and allegations of unauthorized administration of medication by visitors. A resident with heart disease, diabetes, and dementia, who had moderate cognitive impairment, was admitted with conflicting documentation about code status and power of attorney. The facility's records showed inconsistencies between the advanced directives signed by different family members, with one family member signing as DPOA without legal authority and staff failing to verify or document the correct paperwork. The social worker and other staff were aware of Adult Protective Services (APS) involvement but did not document the concerns or actions taken in the clinical record. Additionally, the resident reported fear of specific family members, leading to a ban on their visitation after allegations that one had brought in and administered non-prescribed medication. Despite staff awareness of these concerns, there was no documentation in the medical record regarding the resident's fear, the ban on visitors, or the investigation into the alleged medication administration. Staff interviews revealed a lack of clarity about the events, poor communication, and failure to document critical information related to the resident's safety and care decisions.