Failure to Obtain and Document Resident's Advance Directive
Penalty
Summary
The facility failed to obtain and maintain a copy of an advance directive for one resident who indicated at admission that they had such a document and would provide it. Upon review, the resident's electronic health record only contained a financial Durable Power of Attorney (DPOA), not a healthcare advance directive. Multiple staff interviews confirmed that the DPOA on file was for financial matters only, and there was no documentation or progress notes indicating that follow-up was conducted to obtain the resident's advance directive for healthcare prior to a recent inquiry. The facility's policy requires staff to inquire about advance directives at or near admission and to obtain and file a copy in the resident's health record. Despite the resident's indication that they had an advance directive, there was no evidence in the record that the facility followed up to secure the document or documented any attempts to do so until prompted by the survey process. Staff acknowledged that documentation of follow-up was lacking and that the required healthcare advance directive was not present in the resident's file.