Failure to Provide Opportunity for Advance Directive
Penalty
Summary
The facility failed to provide Resident R87 with the opportunity to formulate an advance directive, which is a written instruction such as a living will or durable power of attorney for health care. This deficiency was identified through a review of the facility's policy on 'Resident Rights Regarding Treatment and Advance Directives' and the clinical records of Resident R87. The policy, dated 1/12/25, indicated that advance directives should be discussed with residents or their representatives to determine if any have been chosen or if there are any questions. However, there was no documentation in Resident R87's clinical record to show that this opportunity was provided. Resident R87 was admitted to the facility on 11/15/24, and their Minimum Data Set (MDS) dated 11/21/24 included diagnoses of high blood pressure, diabetes, and morbid obesity due to excess calories. Despite these health conditions, the clinical record lacked evidence of an advance directive or any documentation that the resident was given the chance to formulate one. This was confirmed during an interview with the Social Services Director, Employee E6, who acknowledged the absence of such documentation in the resident's record.
Plan Of Correction
The resident and/or resident representative for Resident # 87 were immediately provided an opportunity to develop an advance directive. To identify other residents that have the potential to be affected, the DON/designee completed a house audit to ensure residents and/or resident representatives have been provided an opportunity to develop an advance directive. Corrections will be made as needed. To prevent this from recurring, the RDCS/designee educated licensed nursing and Social Services on the regulatory requirements of F578 regarding ensuring residents and/or resident representatives are provided an opportunity to develop an advance directive. To monitor and maintain ongoing compliance, the DON/designee will audit 3 residents weekly x4 then monthly x 2 to ensure residents and/or families are provided an opportunity to develop advance directives. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.