Failure to Assess and Assist with Advance Directives on Admission
Penalty
Summary
The facility failed to assess for or assist in the formulation of advance directives upon admission for a resident. Policy review indicated that on admission, the facility is required to determine if a resident has executed an advance directive and, if not, to determine whether the resident would like to formulate one. Additionally, the social worker or designee is responsible for completing an initial and quarterly assessment to identify any need for medically-related social services, including assistance with advance care planning and completion of advance directives. Record review for the resident in question showed no evidence of advance directives, no assessment for advance directives, and no documentation of assistance by social services regarding advance directives. The resident was admitted with mild cognitive deficits, as indicated by a BIMS score of 11, and was documented as being his own representative. During interviews, the DON stated that Admissions was responsible for assessing advance directives, while the BOM, who was also responsible for admissions and social services, explained that advance directive information is typically obtained from the hospital or previous facility, or by reaching out to the resident or their representative if not provided. However, for this resident, the BOM confirmed there was no documentation or evidence of advance directives in the medical record, and no assessment or assistance had been provided.