Failure to Document and Offer Advance Directives to Residents
Penalty
Summary
The facility failed to honor residents' rights to formulate Advance Directives for five sampled residents. For three residents, the Advance Directives Checklist forms did not indicate whether they were provided an opportunity to formulate an Advance Directive. Specifically, one resident's form acknowledged receipt of information but did not document whether the resident wished to formulate an Advance Directive, and the resident reported not being offered assistance. Another resident's form was incomplete, with unchecked boxes and a responsible party who was unsure what an Advance Directive was or if it had been offered. A third resident's form was undated, unsigned, and did not indicate whether the responsible party was provided with information, despite the resident being severely cognitively impaired and unable to follow commands. For another resident with severe cognitive impairment and no decision-making capacity, the Advance Directives Checklist was faxed to the responsible party for signature, but the form remained unsigned and there was no documentation that the responsible party received the information or was given the opportunity to complete the Advance Directive. In the case of a fifth resident, who had full decision-making capacity, there was no Advance Directives Checklist in the medical record, and the POLST form was incomplete regarding the Advance Directive section. Interviews with facility staff, including the Director of Social Services and the Director of Nursing, confirmed that the process for providing and documenting Advance Directive information was not consistently followed. The facility's policy required that residents or their representatives be provided with written information about Advance Directives upon admission and that this be documented in the health record, but this was not done for the affected residents.