The 2011 document, faxed to the facility in 2013, designated two family members as agents for Resident 5's medical decisions. But when federal inspectors arrived in September following a complaint, they discovered the facility had no record of the directive in the resident's electronic chart.
Instead, staff had been consulting a different relative entirely.
"The proper person was not making the decisions," the facility's Social Services Director told inspectors when confronted with the missing document. "The [other relative] was always involved, so we kept going to her. Was incorrect."
The Social Services Director described the advance directive as "buried."
During the inspection, the facility's Director of Nursing confirmed there was no advance directive in Resident 5's electronic record, despite facility policy requiring such documents be maintained in an accessible location. The director said all documents since 2022 had been uploaded to the new electronic system.
The confusion began with the facility's 2022 transition to electronic charting. While staff uploaded most resident documents to the new system, Resident 5's advance directive remained in paper files that weren't routinely accessed.
A Medical Records Assistant eventually located the 2011 document during the inspection, confirming it designated two specific family members as decision-making agents. No subsequent documentation existed showing the directive had been revoked or changed.
The relative who had been consulted by staff was listed in admission records as the emergency contact and responsible party, but held no legal authority under the advance directive to make medical decisions.
One of the designated agents told inspectors she had faxed the advance directive to the facility in 2013, two years after its creation. She said she wasn't aware whether it had been updated to reflect changes in emergency contact information.
The other designated agent believed she was serving as the emergency contact, according to the Social Services Director, who said she had to correct this misunderstanding based on what appeared in admission records.
The facility's own policy, dated September 2022, requires staff to inquire about advance directives before or upon admission and maintain copies in residents' medical records in readily retrievable locations. The policy states that residents' wishes must be communicated to direct care staff and physicians by placing advance directive documents prominently in medical records.
Federal regulations require nursing homes to honor advance directives according to state law and facility policy.
The Social Services Director admitted having no knowledge of the 2011 advance directive when inspectors showed it to her, despite her role overseeing such documentation. She acknowledged the document should have been transferred to the electronic record system.
The Director of Nursing told inspectors that the relative they had been consulting was frequently at the facility and that staff regularly discussed the resident's care concerns with her. This practice continued even though she lacked legal authority to make medical decisions under the actual advance directive.
The missing directive meant that for nearly three years, medical decisions affecting Resident 5's care were potentially made by someone without legal standing to do so. The two family members specifically chosen by the resident in 2011 to make such decisions were bypassed in the process.
When the Medical Records Assistant finally retrieved the document from old paper files, it clearly showed the two designated agents and contained no indication it had been superseded by newer documentation.
The facility's electronic transition, while intended to improve record-keeping, had effectively erased a critical legal document that should have guided all medical decision-making for the resident. The Social Services Director's description of the directive as "buried" highlighted how the administrative change had obscured essential resident rights documentation.
The inspection revealed that Westview Healthcare Center's failure to maintain proper advance directive records violated federal requirements designed to ensure residents' end-of-life wishes are respected and legally authorized representatives make medical decisions on their behalf.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westview Healthcare Center from 2025-09-11 including all violations, facility responses, and corrective action plans.