Failure to Maintain and Document Advance Directives
Penalty
Summary
The facility failed to maintain accurate and accessible documentation of residents' advance directives (ADs) for four out of six residents reviewed. For three residents, their ADs or Durable Power of Attorney for Health Care (DPOA-HC) documents were not readily available in either their physical or electronic medical records, despite documentation indicating that these documents existed and were acknowledged by the residents or their representatives. The Director of Nursing (DON) confirmed during interviews that these documents should have been present in the residents' charts and acknowledged that their absence could result in staff not following the residents' documented wishes. Additionally, for one resident, there was no documented evidence that information regarding the formulation of an AD was provided upon admission. The resident was cognitively intact, but neither an AD nor an Advance Directive Acknowledgement Form was found in the resident's records. The DON stated that if an AD was not obtained at admission, follow-up and education regarding ADs should have been conducted and documented, but this was not done in this case. The facility's own policy requires that copies of advance directives be obtained, maintained in a consistent and accessible section of the medical record, and that residents or their representatives be provided with written information about their rights regarding advance directives. The policy also specifies that these documents should be easily retrievable by staff and that residents' wishes should be communicated to direct care staff and physicians. These requirements were not met for the residents identified in the report.