Failure to Provide Advance Directive Opportunities
Penalty
Summary
The facility failed to comply with the requirements for advance directives as outlined in 28 Pa. Code 201.14(a) and 483.10(c)(6)(8)(g)(12)(i)-(v). Specifically, the facility did not provide the opportunity for seven residents to formulate an advance directive or conduct periodic reviews of existing directives. This deficiency was identified through a review of facility policies, clinical records, and staff interviews. The residents involved in this deficiency included individuals with various medical conditions such as anxiety, depression, dementia, coronary artery disease, stroke, and schizoaffective disorder. Despite having cognitive abilities ranging from intact to severely impaired, as indicated by their BIMS scores, there was no documentation in their clinical records of advance directives or evidence of periodic reviews. This lack of documentation suggests that the facility did not adhere to its policy of supporting and facilitating residents' rights to make decisions about their medical treatment. During an interview, the Nursing Home Administrator confirmed the facility's failure to provide the opportunity for these residents to formulate or review advance directives. This deficiency affected seven out of the twenty-two residents reviewed, highlighting a significant oversight in the facility's compliance with federal and state regulations regarding resident rights and advance directives.
Plan Of Correction
Residents R11, R35, R41, R45, R52, and R55 have been provided the opportunity to formulate an advance directive. Residents electing to execute advance directives have been provided assistance. The facility has determined that current residents have the potential to be affected. An audit was completed on current residents to ensure each has been given the opportunity to formulate an advance directive. The facility reviewed with each resident their decision regarding advance directive status and provisions. The Nursing Home Administrator, or designee, has re-educated the interdisciplinary team members responsible for advance directives on the facility's "Advance Directives." The facility will offer residents on admission/readmission the opportunity and assistance to formulate an advance directive. The facility will review during the annual care conference with the resident and responsible party the decisions made regarding advance directives. The Director of Social Services, or designee, will review care conference summary notes to ensure each resident has been provided the opportunity to formulate an advance directive and review any previously made decisions regarding advance directives weekly for 2 months. Results of audits will be reviewed by the Quality Assurance Committee quarterly until the committee determines consistent substantial compliance.