Failure to Inform Residents of Rights Regarding Advance Directives
Penalty
Summary
The facility failed to provide information to residents or their responsible parties regarding the right to accept or refuse medical or surgical treatment when formulating advance directives. This deficiency was identified for four out of six sampled residents. For each of these residents, there was no documentation in the medical record indicating that information about the right to accept or decline treatment was provided prior to making decisions about advance directives, such as Full Code or Do Not Resuscitate status. Interviews with the Social Worker confirmed that the facility did not inform or document informing the residents or their responsible parties of these rights. The affected residents included both cognitively intact and severely cognitively impaired individuals, with some decisions made by responsible parties. The lack of documentation and communication was consistent across all reviewed cases, regardless of the resident's cognitive status or advance directive choice.