Failure to Maintain Advance Directives in Resident Records
Penalty
Summary
The facility failed to ensure that advance directives were available in the clinical records for two of four sampled residents. For one resident with a history of diabetes, the care plan indicated the presence of an advance directive and a medical power of attorney, but neither document was found in the medical record. The resident confirmed having completed an advance directive with family, and the care plan required that the directive be honored and kept on file. However, staff were unable to locate the document and were unclear about the distinction between a POLST and an advance directive, using the terms interchangeably. Similarly, another resident with multiple sclerosis had a care plan stating an advance directive was in place and should be honored, but the document was not present in the clinical record. The resident reported completing an advance directive while at the facility. Staff again referenced a POLST as being on file and demonstrated a lack of understanding regarding the difference between a POLST and an advance directive. In both cases, the absence of the required documentation in the medical record was confirmed by staff.