Failure to Ensure Advance Directive Documentation and Communication
Penalty
Summary
The facility failed to implement its policies and procedures regarding Advance Directives (AD) for three residents by not ensuring that information about the existence or execution of ADs was properly documented and accessible in the residents' medical records. For one resident with dementia, COPD, and osteoarthritis, the AD Acknowledgement form indicated an AD had been executed, but no copy was found in the chart or uploaded to the electronic medical record (EMR). The Director of Nursing (DON) confirmed that a copy should have been available to staff to address the resident's end-of-life wishes. Another resident with muscle weakness and mobility issues, who had intact cognition, did not have a completed AD Acknowledgement Form in the medical record. There was also no clinical documentation that Social Services had provided information about ADs or attempted to reach out to the resident or responsible party to offer this information upon admission, as required by facility policy. The DON confirmed that the form should have been completed and discussed with the resident or responsible party at admission. A third resident, with dementia and anemia and lacking decision-making capacity, also did not have documentation in the medical record regarding the existence of an AD or a Physician Orders for Life-Sustaining Treatment (POLST). Progress notes showed that nursing staff only recently attempted to contact the family about the AD and POLST, and the Advance Healthcare Directive Acknowledgment form was not completed. The DON acknowledged that the form should have been completed by Social Services and that there was no documentation of follow-up attempts prior to the recent week.