Failure to Obtain and Maintain Advance Directives Documentation
Penalty
Summary
The facility failed to obtain and/or maintain Advance Directives (AD) documentation for one resident who was alert and oriented. Upon admission and re-admission, there was no documentation in the resident's electronic health record (EHR) regarding the presence of an AD or that information or assistance was provided to develop one. The Social Service Initial Evaluation indicated the resident had a Health Care Durable Power of Attorney (DPOA), and a progress note stated that DPOA paperwork was supposed to be brought to the facility, but it was not present in the record. The care plan did not address ADs, and quarterly notes did not reflect any change or follow-up regarding the AD status. Staff interviews confirmed that the facility's protocol was not followed, as the AD was not readdressed upon the resident's re-admission, nor was a copy requested or obtained during the quarterly care conference. The Social Services Director acknowledged the lack of documentation and stated that reminders to provide the AD were given periodically, but no documentation or follow-up was completed. The Administrator also confirmed that the protocol for obtaining and documenting ADs was not followed for this resident.