Failure to Maintain and Provide Advance Directive Documentation and Information
Penalty
Summary
The facility failed to obtain and/or maintain copies of advance directives and provide written information regarding the formulation of advance directives for four residents. For two residents who had executed advance directives, the facility did not ensure that copies of these documents were available in their medical records or electronic health records. Interviews with nursing and social services staff confirmed that there was no documented follow-up to obtain these documents, despite facility policy requiring such actions and quarterly checks. For another resident who had not executed an advance directive, the facility did not provide written information or assistance on how to formulate one to the resident or their responsible party. Medical record review and staff interviews confirmed the absence of documentation showing that the required information and assistance were offered, as outlined in facility policy. The responsible staff acknowledged that this step was missed during the admission process and subsequent follow-up. A fourth resident, who lacked decision-making capacity, also did not have documentation in the medical record that the responsible party was provided with information on how to formulate an advance directive. The social services director and DON confirmed that, according to policy, this information should have been offered and documented, but there was no evidence of this in the resident's records. These failures were verified through interviews and concurrent record reviews with facility staff and administration.