Failure to Obtain and Document Advance Directive for Resident
Penalty
Summary
The facility failed to ensure that an advance directive, specifically a written instruction such as a living will or Durable Power of Attorney (DPOA) for health care, was obtained and properly documented for one resident. Upon review of the resident's care plan, it was indicated that the resident had an advance directive DPOA. However, examination of the electronic health record revealed only a financial DPOA on file, with no documentation of a health care DPOA or other advance directive. Staff interviews confirmed that the DPOA paperwork available pertained solely to financial matters and did not address health care decisions, despite the care plan indicating otherwise. Further investigation showed that the facility's process involved asking residents at admission if they had an advance directive and requesting a copy for the medical record. In this case, the staff acknowledged that the documentation on file did not meet the requirements for a health care advance directive. The absence of the appropriate advance directive in the resident's record meant that the resident's preferences regarding health care decisions were not properly documented or available to guide care.