Failure to Document Advance Directive Discussions in Resident Records
Penalty
Summary
The facility failed to ensure that residents' medical records were updated to document that advance directives were discussed with residents and/or their responsible parties. Specifically, for four out of fifteen sampled residents, there was no evidence in the medical records that advance directives were addressed as required. These residents included individuals with varying cognitive abilities, such as those who were cognitively intact and those with severe cognitive impairment due to conditions like dementia and Alzheimer's disease. In each case, reviews of admission records, Minimum Data Set (MDS) assessments, and Physician Orders for Life-Sustaining Treatment (POLST) forms showed either the absence of an advance directive or a lack of documentation regarding any discussion about advance directives. Interviews with facility staff, including the Social Service Director (SSD) and the Director of Nursing (DON), confirmed that there was no documentation of advance directive discussions or follow-up with the residents or their responsible parties. The facility's policy required that information about advance directives be provided and documented upon or prior to admission, and that the existence of such directives be prominently displayed in the medical record. However, this process was not followed for the identified residents, resulting in incomplete records regarding their wishes for medical treatment.