Failure to Document Advance Directive Discussions and Provision of Information
Penalty
Summary
The facility failed to ensure that advance directives were discussed with, and information regarding advance directives was provided to, residents and/or their responsible representatives. For one resident who had the capacity to make their own decisions, there was no documented evidence that the facility provided education about or obtained an advance directive. The Director of Social Services confirmed that no advance directive documentation was found for this resident, despite the facility's stated process of evaluating residents on admission and offering the opportunity to formulate advance directives if none were present. For another resident, the medical record included a Maryland Order for Life Sustaining Treatment (MOLST) and a certificate of capacity indicating the resident was cognitively intact and capable of making decisions. However, there was no advance directive document found in either the paper chart or electronic medical record, and no documentation that a discussion about advance directives had occurred with the resident or their responsible party. The Director of Social Services confirmed that the admission assessment and social services progress notes did not document any discussion or provision of information regarding advance directives for this resident.