Failure to Maintain Advance Directives and Guardianship Documentation
Penalty
Summary
The facility failed to ensure proper documentation and assistance regarding advance directives (ADs) and guardianship papers for several residents. For one resident with intact memory at admission, there was no documentation in the chart to show that the facility offered assistance to formulate an AD, nor was there a signed acknowledgement form on file. Staff confirmed that such documentation should exist but were unable to provide it. The facility's policy requires inquiry about AD status upon admission and assistance if needed, but this was not followed in this case. Additionally, for three residents with impaired or severely impaired memory and lacking capacity for medical decision-making, the facility did not maintain current guardianship documentation. In each case, the only guardianship papers on file were expired, and staff confirmed that no current documents were available. The care plans for these residents indicated the need for up-to-date guardianship papers and regular review, but the records did not reflect compliance with these requirements.