Failure to Document Advanced Directives for Two Residents
Penalty
Summary
The facility failed to provide documentation of advanced directives or the opportunity to formulate an advance directive for two residents. Resident R70, admitted on 6/26/23, had no documentation in their clinical record indicating the presence of an advanced directive or that they were given the opportunity to create one. Resident R70's medical history includes cancer, depression, and peripheral vascular disease. Similarly, Resident R77, admitted on 12/6/23, also lacked documentation of an advanced directive in their clinical record. Resident R77's medical history includes cancer, high blood pressure, and diabetes. During interviews, a registered nurse confirmed the absence of advanced directives or documentation of the opportunity to formulate them for both residents. The Director of Nursing also confirmed this deficiency, which violates the residents' rights to formulate an advance directive as per facility policy and state law. The facility's policy, last reviewed on 8/24, mandates that residents or their representatives be provided with written information about their right to formulate an advance directive.
Plan Of Correction
Residents R70 and R77 will be offered the opportunity to complete an Advanced Directive. All residents in the facility will be reviewed to ensure an advanced directive is in place or has been offered to complete one by social services/designee. The facility social services and Admission Director will be educated on requirements to have the opportunity to complete an advance directive. Social Service will offer Advance Directive upon admission and document refusals. Audits of all new admissions will be completed by the SSD/Designee weekly x 4 then monthly x 2 months, to ensure residents are provided the opportunity to complete advanced directives. Audit results will be reviewed through QAPI for further recommendation.