Failure to Assist Residents with Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an Advance Directive, as required by facility policy. Record review, policy review, document review, and staff interviews revealed that for six residents, there was no documentation of Advance Directives in their medical records, nor evidence that the facility had offered assistance in formulating such directives. The facility's policy outlined specific procedures for providing information about medical treatment decisions, obtaining signatures, and referring residents to social services for assistance with Advance Directives, but these steps were not documented as completed for the affected residents. For each of the six residents reviewed, including individuals with diagnoses such as dementia, depression, chronic kidney disease, chronic respiratory disease, chronic obstructive pulmonary disease, anoxic brain damage, diabetes, and chronic viral hepatitis, there was a lack of documentation regarding Advance Directives. The only documentation present was related to CPR status, which the DON confirmed was the extent of the facility's process for Advance Directives. The Social Worker also confirmed that during annual admission reviews, there was no documentation that Advance Directives were discussed or confirmed with these residents. Additionally, the facility's document provided to residents, "Your Rights As A Patient To Make Medical Treatment Decisions," only contained information about living wills and durable power of attorney for health care, and did not include documentation declaring the status of an Advance Directive. This incomplete process and lack of documentation were consistent across all six residents reviewed, indicating a systemic failure to follow the facility's own policy and federal requirements regarding Advance Directives.