Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were given the opportunity to formulate an advance directive or were offered assistance in doing so. This deficiency was identified for six residents during a review of facility policies, clinical records, and staff interviews. The facility's policy, dated November 26, 2024, mandates that upon admission, the facility should determine if a resident has executed an advance directive and provide information about the right to refuse medical or surgical treatment and formulate an advance directive. However, there was no documented evidence in the medical records of the six residents reviewed that these steps were taken. The residents involved had varying degrees of cognitive impairment and required different levels of assistance with care needs. For instance, one resident had mild cognitive impairment and required supervision to moderate assistance, while others were cognitively impaired with diagnoses such as dementia and hemiplegia. Despite these conditions, the facility did not document any efforts to discuss or assist with advance directives, as confirmed by the Director of Nursing during an interview. This lack of documentation and action indicates a failure to comply with the regulatory requirements regarding advance directives.
Plan Of Correction
1. Assistance with completing advanced directives was offered to residents 37, 62, 81, 88, 90. Resident 100 has been discharged from the facility. 2. Audit of all residents in the facility was completed to ensure all residents had been offered the opportunity to formulate an advanced directive. All residents without a current advanced directive are offered the opportunity to complete one. 3. Education completed with the Interdisciplinary team to ensure the opportunity to formulate an advanced directive is being offered during the residents' initial care plan meeting and the opportunity to update/change at a minimum of each care plan meeting thereafter. 4. Audits will be completed on all new admissions weekly x 4 weeks and monthly x 2 months to ensure the opportunity to formulate an advanced directive is being completed. 5. Date of compliance 3/5/2025