Failure to Maintain Medical Power of Attorney Documentation in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's Medical Power of Attorney (POA) advanced directive document was obtained and included in the resident's medical record. The resident, who was admitted with a diagnosis of dementia and assessed as cognitively intact, had her family member listed as her medical POA and Responsible Party (RP) in multiple facility records, including the physician's progress note, care conference record, and face sheet. Despite this, there was no evidence in the medical record of the actual POA document. The resident's RP confirmed that a POA document had been executed and stated he had brought a copy to the facility, though he could not recall when or to whom it was given. Interviews with facility staff revealed confusion and lack of clarity regarding the process for obtaining and filing advanced directive documents. The Medical Records Director reported not having the POA document and explained that such documents would typically be provided by the Social Worker or Admissions Director. Both social workers interviewed denied responsibility for obtaining or receiving POA documents, while the Admissions Director stated he would forward such documents to the Medical Records Director but did not recall receiving one for this resident. The Director of Nursing was unsure of the facility's process for ensuring advanced directives were present in the medical record, and the Administrator confirmed that a copy of the POA should be obtained and scanned into the record, but acknowledged there was no current plan of correction for this issue.