Failure to Maintain Advance Directives in Resident Medical Charts
Penalty
Summary
The facility failed to ensure that copies of executed Advance Directives (ADs) were kept in the active medical charts and were easily retrievable for two residents. For one resident with diagnoses including dysphagia, type 2 diabetes, and anemia, the admission record and Minimum Data Set (MDS) confirmed the resident was able to communicate and required staff assistance for several activities of daily living. The Advance Directive Acknowledgement (ADA) form indicated that the resident had executed an AD and that the facility had received a copy. However, during a review with the Medical Records Director, it was found that the AD was not present in the resident's chart, despite facility policy requiring it to be accessible in case of emergency. The Assistant Director of Nursing (ADON) confirmed that the AD should have been in the chart to guide staff regarding the resident's wishes. For a second resident with diagnoses including dysphagia, dementia, and anemia, the MDS showed severely impaired cognitive skills and a need for substantial staff assistance. The ADA form and a Physician Orders for Life-Sustaining Treatment (POLST) form both indicated that the resident had executed an AD and that the facility had received a copy. However, during a review with the Social Service Director, it was determined that the AD was not present in the resident's chart. The Social Service Director and the ADON both stated that the AD should have been in the active chart to ensure staff could reference the resident's healthcare wishes. The facility's policy and procedure on Advance Directives, last reviewed in January, required that AD documents be placed in a prominent, accessible location in the medical record and that the resident's wishes be communicated to direct care staff and the physician. In both cases, the facility did not follow its own policy, resulting in the absence of the residents' ADs from their medical charts.