Failure to Maintain and Provide Advance Directive Documentation
Penalty
Summary
The facility failed to implement its policy and procedure regarding advance directives for two residents. For one resident with Alzheimer's disease and hypertension, the facility did not maintain a copy of the resident's advance directive in either the electronic medical record or the physical chart, despite documentation indicating that the resident had executed such a directive. During an interview, a registered nurse confirmed the absence of the advance directive in the records and acknowledged the importance of having this document accessible to honor the resident's healthcare wishes, especially in emergencies. The facility's policy requires that a copy of the advance directive be provided for the resident's clinical record if one exists. For another resident with diagnoses including sepsis, pyelonephritis, and lack of coordination, the facility did not provide written information about the right to prepare an advance directive upon admission, nor could staff locate the required acknowledgement form in the resident's records. Interviews with the Social Service Director and the Director of Nursing confirmed that it is standard procedure to check for an advance directive or provide information on how to formulate one at admission. The facility's policy states that residents must be given written information about their rights under state law to prepare an advance directive prior to or upon admission.