Failure to Document Advance Directive Status in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident by not documenting whether the resident had an advance directive (AD) in place, declined to complete one, or was offered assistance to formulate one. A review of the resident's clinical record showed no documentation regarding the AD status. During an interview and review of the electronic health record, an LPN confirmed that there was no information about the resident's AD in the system, and if it was not scanned into the new system, it was not present in the building. The Administrator also confirmed that the resident's AD information was not readily available in the medical record. The resident in question had been admitted to the facility several years prior with a diagnosis of unspecified dementia and was found to be cognitively intact based on a recent BIMS score. A care plan conference was held with the resident, during which it was identified that the resident had no Power of Attorney (POA) or AD in place. Despite this, the facility had not taken steps to ensure that the resident's AD status was documented in the medical record.