Failure to Document or Offer Advanced Directives
Penalty
Summary
The facility failed to provide documentation of advanced directives or offer the opportunity to formulate an advance directive for two residents. The facility's policy on 'Advanced Directives Information' states that advanced directives are written instructions about future medical care if a resident becomes unable to make decisions for themselves. The policy also indicates that these directives should be discussed with the resident or their representative, and any chosen directives should be documented in the medical record. For Resident R31, who was admitted to the facility in 2013 and has diagnoses including high blood pressure, diabetes, and aphasia, there was no documentation of an advanced directive or evidence that the resident was given the opportunity to formulate one. Similarly, for Resident R42, admitted in 2017 with diagnoses of high blood pressure, anemia, and hyperlipidemia, the clinical record lacked documentation of an advanced directive or evidence of an opportunity to formulate one. The Regional Clinical Director confirmed the facility's failure to provide the necessary documentation or opportunity for these residents.
Plan Of Correction
The resident and/or resident representative for Resident #31 and #42 were provided an opportunity to develop an advance directive. Moving forward, SSD/designee will verify residents and/or resident representatives have been provided an opportunity to develop an advance directive upon admission and at each quarterly care conference. To prevent this from recurring, the RDCS/designee educated licensed nursing 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 an advance directive. 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.