Failure to Provide Advance Directive Opportunities
Penalty
Summary
The facility failed to comply with the requirements related to advance directives for three residents. The deficiency was identified during a survey that reviewed facility policies, clinical records, and included staff interviews. The facility's policy on advance directives, last reviewed on November 5, 2024, mandates that all adult residents be informed about their rights to accept or refuse medical treatment and to formulate an advance directive. However, the clinical records for three residents did not contain documentation that they were given the opportunity to formulate an advance directive. Resident R41, who was readmitted to the facility with diagnoses including muscle weakness, high blood pressure, and heart failure, had no documentation of being offered the opportunity to create an advance directive. Similarly, Resident R75, admitted with dyspnea, muscle weakness, and epilepsy, and Resident R77, admitted with high blood pressure, dysphagia, muscle weakness, and liver transplant status, also lacked such documentation. The Director of Nursing and the Admissions Director confirmed the absence of this documentation during interviews conducted on January 24, 2025.
Plan Of Correction
1. R41 has a completed advanced directive, R75 has a completed advanced directive, R77 has a completed advanced directive. 2. A full house audit has been completed to ensure current residents have a current advanced directive. 3. New admissions to the facility will have the opportunity to formulate an advanced directive. Advanced directives will be placed as an order in the medical record. Advanced directives will be reviewed on a quarterly basis with the IDT team and the resident and/or family. 4. The Social Service Director or designee will review new admission medical charts for advanced directives weekly x4 to ensure current advanced directives are in place. The QAPI committee will determine the need for further audits.