Failure to Document and Provide Advanced Directive Information
Penalty
Summary
The facility failed to ensure that documentation regarding residents' advanced directives was accurate and present in the clinical records for 20 out of 24 sampled residents. Record reviews revealed that both electronic and paper medical records for these residents lacked evidence that the facility had offered, reviewed, or provided written information about the right to formulate an advanced directive to the residents or their representatives. This deficiency was identified through a comprehensive review of multiple residents' records, which consistently showed missing documentation related to advanced directives. The absence of such documentation was noted across a significant number of residents, indicating a widespread issue rather than isolated incidents. The findings were confirmed during interviews with facility leadership, including the Director of Nursing and the Administrator, who acknowledged the lack of proper documentation. No information was provided in the report regarding the specific medical histories or conditions of the affected residents at the time of the deficiency. The focus of the findings was solely on the facility's failure to provide and document the required information about advanced directives as mandated by policy and regulation.