Failure to Assist Resident in Formulating Advance Directive
Penalty
Summary
Heritage Ridge Senior Living was found to be non-compliant with the requirements of 42 CFR Part 483, Subpart B, specifically regarding the rights of residents to formulate advance directives. The facility's policy, dated January 20, 2025, mandates that upon admission, residents or their representatives should be provided with written information about their rights to accept or refuse medical treatment and to formulate an advance directive. However, it was determined that the facility failed to ensure that a resident, identified as Resident 33, was given the opportunity to develop an advance directive or assisted in formulating one. This was based on a review of facility policies, clinical records, and staff interviews. Resident 33, who was mildly cognitively impaired and had a history of mental health conditions including schizoaffective disorder, bipolar disorder, anxiety, depression, and PTSD, did not have advance directives documented in their medical records. The quarterly Minimum Data Set assessment indicated the resident's cognitive and behavioral status, yet there was no evidence in the clinical record that the resident or their representative was offered assistance in formulating an advance directive. The Director of Nursing confirmed the absence of documentation regarding the opportunity for the resident to formulate an advance directive.
Plan Of Correction
The Director of Nursing provided resident 33 with information on how to formulate advance directives. Baseline audit was completed to identify residents without advanced directives and residents/resident representatives were provided with information on how to formulate advance directives. Advance directive status will be evaluated at the time of admission. Residents who do not have advance directives will be provided with information on formulating advance directives. Advance directive status will be reviewed quarterly. Monitoring will be captured through auditing advance directive status as follows: up to 3 clinical records weekly for 4 weeks, then up to 6 clinical records 2 times monthly for 2 months. The audits will be conducted by the Social Worker or designee. Results of the audits will be provided to the Administrator and be presented for review at the monthly Quality Assurance Improvement Committee (QAPI) meeting for a period of three months. Any revisions to the audit plan will be reviewed and implemented with coordination of the interdisciplinary team at the QAPI Committee meeting.