California Nursing Home Administrator License Practice Exam

What must be documented if a resident has a health care surrogate or power of attorney?

1. This must be documented in the medication observation record (MOD)

2. This must be documented on the admission/discharge log

3. This must be documented in the resident record

4. This must be documented in the major incident log

The correct answer is: This must be documented in the resident record

When a resident has a health care surrogate or power of attorney, it is essential that this information be documented in the resident record. This documentation ensures that all staff members are aware of who has the legal authority to make health care decisions on behalf of the resident, promoting clarity and continuity of care. Having this documented in the resident record is critical for proper communication among the healthcare team, as it allows for informed decision-making that aligns with the resident's wishes as expressed through their designated surrogate or power of attorney. In addition, it can provide legal protection for the facility and staff by confirming that decisions are made in accordance with the resident's rights and preferences. Other options, while they may relate to certain aspects of care or administration, do not serve the same function as documenting this information in the resident record. For example, documenting on the medication observation record or admission/discharge log would not provide the comprehensive view needed for care decisions by surrogate decision-makers. Similarly, the major incident log is focused on unusual events that might occur within the facility, not on ongoing healthcare directives. Thus, ensuring that the information is in the resident record is both a practical and a legal necessity in the management of resident care.