Advance Directive Not Available in Resident’s Record
Penalty
Summary
The facility failed to ensure a resident’s current advance directive or MOST form was available in the Electronic Health Record (EHR) or in physical form for staff use. The resident, admitted on 10/14/25, had a diagnosis of Huntington’s disease. Record review of the resident’s face sheet confirmed the admission date and diagnosis, and further review of the EHR showed there was no advance directive or MOST form completed or available for this resident. During an interview on 01/07/26 at 1:16 pm, the DON reported that she searched for the resident’s advance directive but could not locate it and confirmed that the resident did not have an advance directive or MOST form readily available, despite the expectation that one should have been accessible. This deficient practice was identified by surveyors as likely to cause confusion and delay potentially lifesaving procedures.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.