Failure to Provide Advance Directive Information and Documentation
Penalty
Summary
The facility failed to provide information and documentation regarding residents' rights to formulate an advance directive for four out of thirty-three sampled residents. According to the facility's policy, the social services director or designee is required to inquire about the existence of any written advance directives and provide written information about the right to accept or refuse medical or surgical treatment and to formulate an advance directive prior to or upon admission. However, for the identified residents, the facility was unable to produce completed documentation showing that either the residents or their representatives were educated about advance directives. The affected residents included individuals with diagnoses such as Alzheimer's Disease, Anxiety, Depression, Diverticulosis, Chronic Obstructive Pulmonary Disease, Bipolar Disorder, Hypertension, Cerebral Infarction, Diabetes, Parkinson's Disease, Left Femur Fracture, Osteoporosis, and Dementia. Some of these residents were severely cognitively impaired, as indicated by low BIMS scores or incomplete assessments, necessitating that their representatives be informed. Despite this, there was no evidence that the required education or documentation was provided. The Social Services Assistant confirmed the absence of advance directive documentation for these residents during an interview.