HospitalInspections.org

Based on medical record review and staff interview, the facility failed to ensure Advanced Directives were addressed in eight (8) out of 10 patient charts reviewed: Patients #1, #2, #4, #5, #6, #7, #8, and #10.

Findings Include:

Review of medical record for Patient #1, revealed no documented evidence the Advance Directive Acknowledgement was completed on admission date of 4/15/2021.

Review of medical record for Patient #2 revealed no documented evidence the Advance Directive Acknowledgement was completed on admission date of 4/16/2021.

Review of medical record for Patient #4 revealed no documented evidence the Advance Directive Acknowledgement was completed on admission date of 4/20/2021.

Review of medical record for Patient #5 revealed no documented evidence the Advance Directive Acknowledgement was completed on admission date of 4/20/2021.

Review of medical record for Patient #6 revealed no documented evidence the Advance Directive Acknowledgement was completed on admission date of 4/13/2021.

Review of medical record for Patient #7 revealed no documented evidence the Advance Directive Acknowledgement was completed on admission date of 4/16/2021.

Review of medical record for Patient #8 revealed no documented evidence the Advance Directive Acknowledgement was completed on admission date of 4/20/2021.

Review of medical record for Patient #10 revealed no documented evidence the Advance Directive Acknowledgement was completed on admission date of 4/20/2021.

During an interview on 04/21/2021 at 3:00 p.m., Staff #1, the Clinical Educator, confirmed the "Advanced Directive Acknowledgement" was not addressed but should be.

Exit conference on 04/22/2021 at 2:00 p.m. with Clinical Educator, Quality Director, Director of Nursing, Vice President of Human Resources and Administrator, no further documentation submitted for review.