Failure to Ascertain and Offer Advance Directives
Penalty
Summary
The facility failed to ascertain whether two residents had advance directives upon admission and did not offer them the opportunity to formulate one. The facility's policy, last reviewed on December 2, 2024, requires that upon admission, a team member should meet with the resident to discuss and offer to formulate an advance directive. However, for Resident 74, who was admitted with diagnoses including esophageal cancer and metabolic encephalopathy, there was no documented evidence that the facility determined if the resident had an advance directive or offered information to formulate one. The resident's clinical record only contained a Pennsylvania Physician Orders for Life-Sustaining Treatment (POLST) but lacked any advance directive documentation. Similarly, Resident 18, admitted with unspecified dementia and severe cognitive impairment, also had a POLST indicating a DNR status but no documented evidence of an advance directive or that the facility discussed or offered the opportunity to formulate one with the resident's representative. An interview with the social services director confirmed the absence of documentation indicating that the facility had determined the presence of advance directives for these residents or informed them of their rights to formulate one.
Plan Of Correction
Correction does not constitute an admission of or agreement with the facts and conclusions set forth on the survey report. The plan of correction is prepared and executed as a means to continually improve the quality of care and to comply with all applicable state and federal regulatory requirements. Resident 18 is deceased. Advanced directives have been offered to resident 74 and documented in clinical chart. To identify residents with the potential to be affected, SS/designee will audit current residents to determine if advanced directives have been offered. Any resident not offered will be offered and documented in clinical record. To prevent re-occurrence, the Social Service Director will be educated by NHA/designee on the proper process for advanced directives. To monitor and maintain compliance, the Social Service Director/designee will audit new admissions for advanced directives weekly for 4 weeks, then monthly for 2 months. All findings will be brought to the QAPI committee.