Failure to Provide and Document Advance Directive Information for Residents
Penalty
Summary
The facility failed to inform and provide written information to all adult residents regarding their right to accept or refuse medical or surgical treatment and to formulate an advance directive, as required by regulation. For three of six residents reviewed, there was no evidence in the medical records that the facility had requested or obtained copies of legal documents such as a power of attorney (POA) or living will, despite residents or their families stating these documents existed. Documentation in the electronic health records was limited to code status, with no supporting legal paperwork or evidence that advance directive information was provided or discussed in detail at admission. One resident with severe cognitive impairment was admitted with a family member listed as POA, but the facility did not have a copy of the legal POA document in the record and could not provide it upon request. Another resident, moderately cognitively impaired, and her family indicated that a living will existed and had been discussed with the facility at admission, but no documentation of the living will was found in the chart. A third resident, cognitively intact, stated she had a living will and believed her son had provided it, but again, there was no evidence in the record that the facility had received or documented the living will or provided information about it. Interviews with facility staff, including the Admissions Coordinator, DON, and Executive Director, revealed that while there were processes in place to discuss advance directives at admission and during care plan meetings, there was a lack of consistent follow-up and documentation. Staff acknowledged that communication and follow-up with families regarding advance directive paperwork needed improvement, and that documentation of these discussions and receipt of legal documents was not always completed or tracked effectively.