Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide two residents, identified as Resident R47 and Resident R142, with the opportunity to formulate an advance directive upon admission or re-admission. According to the facility's policy on Resident Rights Regarding Treatment and Advance Directives, dated 12/3/24 and previously dated 9/12/24, the facility is required to determine if a resident has executed an advance directive upon admission and, if not, to offer the opportunity to formulate one. However, a review of Resident R47's admission record, who was admitted on 3/10/23, and Resident R142's re-admission record, revealed no documentation of an advance directive or evidence that they were given the opportunity to create one. Resident R47's Minimum Data Set (MDS) dated 11/8/24, indicated diagnoses of depression, diabetes, and hyperlipidemia, while Resident R142 was re-admitted with diagnoses including high blood pressure, wound infection, and pain. During an interview on 12/17/24, Social Worker Employee E4 confirmed the absence of documentation in the clinical records for both residents regarding the opportunity to formulate advance directives. This oversight is a violation of the residents' rights as outlined in 28 Pa. Code: 201.29(b)(d)(j).
Plan Of Correction
Whole house audit completed on advance directives to ensure advance directives are formulated. Advance directives, offering, documentation has been completed for residents. Resident R47 and R142 were interviewed to discuss advance directives wishes. Education on advance directives will be provided to the social worker and nursing management by the NHA or designee on or before 2/18/2025. Audits will be conducted on advance directive process by NHA or designee weekly x 4 weeks and monthly x 1 month. Audit results will be reviewed through the monthly QAPI process/meeting.