Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide four residents and/or their representatives with written information regarding their right to accept or refuse medical or surgical treatment, as required by the facility's Advance Directive policy. The policy specifies that upon admission or readmission, the Social Services Director is responsible for informing and educating residents or their Power of Attorney in writing about these rights. However, record reviews for four sampled residents revealed no evidence of signed acknowledgements or documentation that written information about these rights was provided. In each case, the Social Services Coordinator/Social Worker did not complete the advance directive checklist at admission, resulting in the absence of required documentation in the residents' records. The affected residents had various significant medical conditions, including hemiplegia, chronic obstructive pulmonary disease, atrial fibrillation, end stage renal disease, dementia, and other chronic illnesses. Some residents were cognitively intact, as indicated by their BIMS scores, while others were not. Despite the presence of physician orders and, in some cases, completed POLST forms, there was no documentation that the residents or their representatives received written information about their rights to accept or refuse treatment, as mandated by facility policy.