Failure to Offer Advance Directive Assistance
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to develop an advance directive, as required by their policy. This deficiency was identified for two residents during a review of facility policies, clinical records, and staff interviews. The facility's policy, dated August 28, 2024, mandates that upon admission, the social services director or designee should inquire about the existence of any written advance directive and provide information on the right to refuse or accept medical treatment and to formulate an advance directive. If no advance directive exists, the facility staff should offer assistance in establishing one, and document the offer and the resident's decision in the medical record. For Resident 10, who was cognitively impaired and dependent on care, and Resident 46, who was cognitively intact but required assistance for care needs, there was no documented evidence in their clinical records that they or their representatives were given the opportunity to develop an advance directive. Additionally, there was no documentation of their decisions to accept or decline assistance in formulating advance directives. This lack of documentation was confirmed during an interview with the Nursing Home Administrator.
Plan Of Correction
1. The identified concern for R10 and R46 cannot be corrected. The responsible party will be notified of the identified concern. 2. The Director of Nursing or designee will audit current resident's medical records to determine if there is an advanced directive on file. 3. The Director of Nursing or designee will re-educate admission staff on ensuring that the resident and/or resident representative are given the opportunity to develop or decline assistance in formulating an advanced directive. 4. The Director of Nursing or designee will audit new residents' medical records for the documented evidence of the resident and/or resident representative decision to accept or decline assistance in formulating advanced directives. The audits will be conducted weekly x4 and monthly x2. All findings will be submitted to the Quality Assurance Committee.