Failure to Document Advance Directive Decisions in Medical Records
Penalty
Summary
The facility failed to document whether five residents had advance directives or their decisions regarding advance care planning, living wills, and power of attorney in their medical records. This deficiency was identified through a review of facility policy, medical records, and staff interviews. The facility's policy required that all information regarding advance directives be included in the Patient Rights booklet and documented in the medical record. However, for the five residents reviewed, there was no documentation of their advance directive status or related decisions. The affected residents had various medical conditions, including displaced fracture, diabetes with neuropathy, COPD, chronic kidney disease, dementia, hypothyroidism, anxiety, discitis, sepsis, osteomyelitis, dysphagia, chronic respiratory failure, metabolic encephalopathy, atrial fibrillation, adult failure to thrive, and heart failure. Cognitive assessments showed that some residents were severely impaired, while others had moderate or intact cognition. Despite these varying levels of cognitive function and complex medical histories, the facility did not record any information about their advance directives in the medical records, as confirmed by the Director of Nursing.