Failure to Provide Advance Directive Information Upon Admission
Penalty
Summary
The facility failed to follow its policy regarding advance directives for two residents. For the first resident, who was admitted with immunodeficiency and schizoaffective disorder and was assessed as moderately impaired in cognitive skills, there was no documentation of advance directive acknowledgement in the medical chart or electronic health record. The Social Services Director confirmed that this acknowledgement should have been completed within 72 hours of admission but was not done. For the second resident, admitted with sepsis, acute respiratory failure, and immunodeficiency, and documented as lacking capacity to make decisions, there was also no advance directive acknowledgement in the chart or electronic record. The Social Services Director and the Director of Nursing both confirmed that the facility's policy requires this acknowledgement within 72 hours of admission, but it was not completed for this resident either.