Failure to Maintain and Honor Advance Directive Results in Improper Notification of Resident's Death
Penalty
Summary
The facility failed to maintain and utilize the current Advance Health Care Directive (AD) for a resident, resulting in the designated agents for Power of Attorney for Health Care (POA) not being notified of the resident's death. The resident, who had multiple diagnoses including multiple sclerosis, epilepsy, and dysphagia, was admitted in 2012 and had a moderate cognitive impairment as indicated by a BIMS score of 9 out of 15. The resident's AD, dated 2011, named two individuals as designated agents for health care decisions, but the facility's records listed other individuals as emergency contacts and responsible parties. Upon the resident's decline and subsequent death, the facility notified the first emergency contact, who was not listed as a designated agent in the AD, and coordinated post-mortem arrangements with this individual. The actual designated agents, as specified in the AD, were not contacted by the facility and only learned of the resident's death through the mortuary. Interviews revealed that the facility was unable to locate the AD in the electronic record at the time of the incident, despite the document having been faxed to the facility in 2013 and later found in past files. Facility staff, including the DON, Social Services Director, and Medical Records Assistant, confirmed that the AD was not uploaded into the electronic record when the system changed in 2022, and that the staff had been relying on the emergency contact rather than the designated agents for decision-making and notifications. The facility's policy required that advance directives be maintained in a readily retrievable location in the medical record and that the resident's wishes be communicated to direct care staff and physicians, but this was not followed in this case.