Failure to Obtain and Maintain Advance Directives and Guardianship Documentation
Penalty
Summary
The facility failed to obtain, maintain, or renew guardianship papers and advance directive (AD) documentation for six residents reviewed for these requirements. According to facility policy, the social services director or designee is responsible for inquiring about and obtaining ADs prior to admission, maintaining these documents in the medical record, and ensuring the care plan reflects the resident's preferences. However, for multiple residents with cognitive impairments, complex medical conditions, or on hospice care, there was no evidence in their records of the required AD or durable power of attorney (DPOA) paperwork, despite documentation or verbal reports indicating such documents existed or were in process. For example, one resident with non-Alzheimer’s dementia stated their daughter was their DPOA, but the facility did not have the paperwork on file, even though a physician's note referenced consulting the DPOA. Another resident on hospice care had a consent form indicating a POA, but no POA paperwork was found in the record. In several cases, admission or social service assessments noted that a family member was the POA or that AD documents were being provided, but there was no follow-up or documentation that these documents were ever received or maintained in the resident's file. Care plans often referenced following resident preferences, but lacked specific documentation of ADs or who to contact for health decisions. Interviews with staff revealed that while the admissions nurse or social worker was expected to obtain ADs, there was no consistent follow-up to ensure the documents were actually received and filed. Staff acknowledged that ADs were important for honoring resident preferences and for knowing who to contact in emergencies, but confirmed that the necessary paperwork was missing from the records of the affected residents. This lack of documentation was observed across multiple residents with varying degrees of cognitive impairment and medical complexity.