Failure to Maintain Accessible Advance Directive and POLST in Resident's Chart
Summary
The facility failed to ensure that an advance directive and a Physician Orders for Life Sustaining Treatment (POLST) were accessible in the medical records of a resident. This deficiency was identified during a review of the resident's paper chart, which did not contain a copy of the advance directive and the original POLST. Interviews with facility staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), confirmed that it was the facility's practice and protocol to have these documents in the physical paper chart to guide care during emergencies. The absence of these documents in the chart was acknowledged by the staff, who emphasized the importance of having them readily available to prevent delays in care. The resident involved had a history of dementia, seizures, and urinary tract infections, and was assessed as having severely impaired cognitive skills, requiring significant assistance with daily activities. The facility's policy and procedure documents indicated that the advance directive and POLST should be filed in the resident's clinical record and be easily accessible. The Director of Nursing (DON) also confirmed the expectation that these documents be present in the resident's chart, highlighting the potential for delayed or negatively affected care if they were missing.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Staff did not provide written information or assistance regarding advance directives to multiple residents, despite facility policy requiring this. Documentation referenced an 'Advance Directive Handbook' that did not exist, and no evidence of advance directive education or offers of assistance was found.
Facility staff did not consistently provide or document advance directive information for several residents with complex medical conditions. Some residents reported not receiving any explanation about advance directives before signing forms, and required documentation was incomplete or missing. These deficiencies were identified through record reviews and interviews, revealing a lack of adherence to facility policy regarding advance directive discussions.
Facility staff did not ensure that a DDNR form for a resident with intact cognition was signed by the ordering medical provider, as required. The form was present in the clinical record but lacked the necessary provider signature at the time of review.
Facility staff did not ensure that two residents, one with moderate cognitive impairment and another with intact cognition, were given the opportunity to formulate advance directives. Both were coded as full code in their records, but interviews and documentation review confirmed that neither had been offered or completed advance directive forms, and staff could not locate the necessary documentation or resources.
Facility staff failed to offer a resident with chronic respiratory failure and moderate cognitive impairment the opportunity to develop an Advance Directive. Despite facility policy requiring such discussions upon admission, no documentation was found, and the President of Quality confirmed the absence of advance directive information.
The facility failed to ensure that residents and/or their representatives had the opportunity to develop an Advance Directive for 19 out of 24 residents reviewed. Surveyors found that the facility did not provide the required written information about formulating advance care plans. Only 13 residents had a tracking form on record, and none documented the provision of written information. The facility's procedure did not meet regulatory requirements for advance care planning.
Failure to Provide Written Advance Directive Information and Assistance
Penalty
Summary
Facility staff failed to provide written information regarding the right to formulate an advance directive to 11 out of 30 sampled residents. Clinical record reviews showed that these residents had signed an acknowledgment of receipt of admission information, which included a reference to an 'Advance Directive Handbook.' However, interviews with the administrator revealed that no such handbook existed, and there was no evidence that advance directive education had been provided to the residents. The administrator also confirmed that the facility did not currently offer assistance to residents in formulating advance directives, despite this being referenced in the facility's policy. The facility's own Advance Directive policy requires that residents be given written information about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive, as well as a description of the facility's policies and applicable state law. The policy also states that staff should offer assistance in establishing advance directives and document the offer and the resident's decision in the medical record. No documentation or evidence was found to show that these requirements were met for the affected residents.
Failure to Provide and Document Advance Directive Information for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that multiple residents were provided with the opportunity to formulate, review, or discuss advance directives upon admission or during their stay. Several residents with significant medical histories, including conditions such as peripheral vascular disease, respiratory failure, congestive heart failure, diabetes, atrial fibrillation, and dementia, were not given clear information or the chance to express their wishes regarding advance directives. In some cases, documentation of advance directive discussions was missing, incomplete, or not witnessed, and residents reported that no one had reviewed the information with them prior to their signatures being obtained. For example, one resident with chronic illnesses was listed as their own responsible party and had a form marked as declined, but when interviewed, indicated that no one had explained advance directive information before the form was signed. Another resident, who was alert and oriented, had a DNR order and a signed advance directive form, but also stated that the facility staff had not reviewed advance directive information with them upon admission. In both cases, the forms lacked witness signatures, and there was no evidence in the clinical record that the required discussions had taken place. Additionally, a resident with a DDNR order had an incomplete form, with required sections left unchecked, and other residents with cognitive capacity were not provided with or did not recall receiving information about advance directives. Facility policy required that advance directive information be provided and discussed upon admission, but documentation and resident interviews revealed that this process was not consistently followed. These deficiencies were identified through clinical record reviews, resident and staff interviews, and examination of facility policies.
Unsigned DDNR Form by Medical Provider
Penalty
Summary
Facility staff failed to ensure that a Durable Do Not Resuscitate (DDNR) form for one resident was signed by the ordering medical provider. The resident was assessed as having intact or borderline cognition, with a Brief Interview for Mental Status (BIMS) score of 14 out of 15, and was able to make self understood and understand others. The clinical record included a DDNR order form that was completed and dated, but it lacked the required medical provider signature at the time of review. This omission was identified during staff interviews and clinical record review, and the unsigned form was presented to surveyors as evidence of the deficiency.
Failure to Offer Opportunity to Formulate Advance Directives
Penalty
Summary
Facility staff failed to ensure that two residents were given the opportunity to formulate an advance directive. One resident, with diagnoses including depression and multiple physical impairments, was admitted and readmitted to the facility, and was assessed as having moderately impaired cognitive abilities. Despite being coded as a full code in the medical record, there was no documentation that the resident had been offered the opportunity to develop an advance directive, and the resident was unaware of having one. Another resident, with chronic kidney disease and other medical conditions, was also admitted and readmitted, and was assessed as cognitively intact. This resident was similarly coded as a full code, but there was no evidence in the records or from staff interviews that the resident had been given the opportunity to formulate an advance directive. Interviews with the Social Services Director, nursing staff, and DON revealed that no advance directive documentation was available for these residents, and the usual storage locations for such documents were missing or unavailable.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility staff failed to ensure that a resident and/or the resident representative had the opportunity to develop an Advance Directive. This deficiency was identified for one of the eighteen current residents, specifically Resident #16. The resident's diagnoses included chronic respiratory failure and adult failure to thrive. According to the quarterly Minimum Data Set (MDS) assessment, the resident had a Brief Interview for Mental Status (BIMS) score of 10 out of 15, indicating moderate cognitive impairment. During the record review, the surveyor could not find any documentation indicating that the resident or their representative had been offered the opportunity to develop an Advance Directive. The issue was discussed with the facility's Director of Clinical Support, President of Quality, Director of Nursing, and President of Nursing Services. Despite the facility's policy stating that Advance Directives should be discussed with residents or family members upon admission or when clinically appropriate, the facility staff could not provide evidence of such a discussion for Resident #16. The President of Quality confirmed the absence of advance directive information for this resident. No further information was provided to the survey team before the exit conference.
Failure to Ensure Advance Directive Opportunities for Residents
Penalty
Summary
The facility staff failed to ensure that residents and/or their representatives had the opportunity to develop an Advance Directive for 19 out of 24 residents reviewed. The facility's policy requires that Advance Care Planning be conducted upon each patient's admission, with a meeting to discuss preferences such as Living Wills and Medical Power of Attorney. However, surveyors found that the facility did not provide written information about formulating advance care plans as required by regulations. During the survey, it was noted that the facility had changed its clinical record software, which may have contributed to the difficulty in locating documentation concerning advance care planning in resident records. Upon reviewing the records of 24 residents, surveyors found that only 13 had a tracking form on record, while 11 did not have any documentation of a care planning discussion. None of the tracking forms documented the provision of written information to the residents or their representatives. Additionally, the only options documented as chosen by residents were Full Code and Do Not Resuscitate, with no documentation of other care-limiting orders or Durable Power of Attorney. The surveyors concluded that the facility did not have a procedure that met regulatory requirements for providing written information about advance care planning and ensuring a meaningful opportunity for residents to formulate and implement these plans.
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