Failure to Complete Advance Directive Acknowledgment Forms for Two Residents
Penalty
Summary
The facility failed to ensure completion of advance directive acknowledgment forms for two sampled residents, as required by its January 2024 Advance Directive Policy and Procedure, which states that upon admission staff must identify whether a resident has an advance directive and, if not, determine if the resident wishes to formulate one, and that all advance directive documents will be obtained and placed in the resident’s chart. Record review showed that one resident, admitted on an unspecified date, had a physician’s order dated 12/09/24 indicating full code status, but there was no advance directive acknowledgment form in the medical record. A second resident, also admitted on an unspecified date, had a physician’s order dated 09/08/25 indicating full code status, with no advance directive acknowledgment form located in the medical record. During interview on 12/16/2025 at 1:42 p.m., the admission director stated the acknowledgments were not in the records because they were waiting for the families to provide them. These findings occurred in the context of a census of 112 residents, with 23 sampled residents reviewed for advance directives, and demonstrated that for at least two residents the facility did not complete the required acknowledgment documentation at or after admission despite having established policy and existing code status orders.
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