Incomplete Advance Directive Documentation in Medical Record
Penalty
Summary
The facility failed to ensure that a resident's complete advance directive was included in their medical record. Upon review, only one page of the resident's advance directive, specifically part four general provisions, was found in the clinical record, while the remaining pages were missing. Documentation showed that the resident had executed an advance directive, and a quarterly assessment indicated the resident had intact cognition. The facility's policy requires that information about whether a resident has executed an advance directive be displayed prominently in the medical record. Interviews with facility staff revealed that the social service director was aware the resident had an advance directive, as they had assisted in its completion, but was unsure of the location of the missing pages. The social service director suggested that the missing documentation might not have been scanned back into the resident's chart following a hospital transfer. The DON confirmed that the resident had marked the advance directive, specifically indicating a desire for a DNR, but was unable to provide documentation clarifying this information.