Failure to Offer and Assist with Advance Directives
Penalty
Summary
The facility failed to follow its policy and procedure regarding advance directives (AD) for six of eight sampled residents. For each of these residents, the clinical records and physician orders for life-sustaining treatment (POLST) forms indicated that no advance directive was documented. There was no evidence in the records that the facility discussed, offered, or assisted these residents in executing an advance directive upon admission or during their stay. Interviews with the Social Service Director (SSD) and Director of Nursing (DON) confirmed that the process of offering and assisting with advance directives was not completed for these residents. The facility's policy required that when an advance directive was not completed, the SSD or other designated staff should schedule a visit from the Ombudsman or patient advocate to assist the resident in completing the document. This step was not taken for the affected residents, as confirmed by both the SSD and DON during record reviews and interviews.