Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to provide evidence that advance directives were offered, reviewed, or that written information regarding the right to formulate an advance directive was given to residents and/or their representatives. This deficiency was identified for four residents who were admitted between December 2024 and February 2025. For each of these residents, a review of both electronic and paper medical records did not show documentation that the facility had fulfilled its obligation to inform or discuss advance directives with the residents or their representatives. Specifically, the records for these residents lacked any indication that the facility had provided the required information or engaged in the necessary discussions about advance directives at the time of admission. These findings were confirmed during interviews and record reviews, and the absence of documentation was discussed with the Market Clinical Advisor on two separate occasions.