Failure to Address Advance Directives for Residents
Penalty
Summary
The facility failed to comprehensively address the formulation of advance directives for two residents, leading to a deficiency in honoring residents' rights to make informed decisions about their medical care. Resident R36, who was admitted with diagnoses including pervasive developmental disorder, unspecified psychosis, difficulty speaking, and dementia with agitation, was identified as a Full Code. However, the facility did not have evidence of a POLST or advance directive in the resident's clinical record, nor was there documentation of discussions or assistance offered regarding advance directives. Interviews with nursing staff confirmed the absence of these critical documents in the resident's record. Similarly, Resident R4, admitted with diagnoses of dementia, hyperlipidemia, and chronic obstructive pulmonary disease, had an order for Do Not Resuscitate (DNR) but lacked evidence of being provided with written information or assistance in formulating advance directives. The Director of Nursing confirmed the absence of such documentation in Resident R4's clinical record. These findings indicate a failure to adhere to the facility's policy on advance directives, which requires providing residents with information and assistance in formulating their medical care preferences.
Plan Of Correction
1. Resident 36 and Resident 4 responsible parties were notified and reviewed Advance directive option. Physician Orders for Life-Sustaining Treatment (POLST) were completed for both residents and physician and families notified. 2. Current resident records were reviewed to ensure that current residents have a code status and a current POLST of their wishes for healthcare. 3. Director of Nursing or designee will provide education to licensed nurses and the social worker on the advance directive policy and the completion of advanced directives on admission. 4. Director of Nursing will audit admissions to ensure that current residents have a code status including a current POLST. Audits will be completed 3 times weekly for 2 weeks then Monthly until compliance is met. Audits will be reviewed at Quality Assurance meetings monthly until compliance is met.