Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to inform and provide written information regarding advance directives to residents or their representatives, as required. For three sampled residents, there was no documentation in either the hard chart or electronic medical record indicating that advance directive information had been provided. These residents included individuals who were both cognitively intact and severely cognitively impaired, with diagnoses such as congestive heart failure, hypertension, renal insufficiency, diabetes mellitus, depression, schizophrenia, anxiety, bipolar disorder, and a history of traumatic brain injury. All three residents were documented as full code status in their physician orders and care plans, but there was no evidence that advance directive options or information had been discussed or offered. During interviews, the Business Office Manager (BOM) confirmed that the facility did not address advance directives with newly admitted residents or their representatives and did not have a process in place to offer information or education about advance directives to current residents. The BOM also stated that while the admission packet included a section on resident rights, it did not contain specific information related to advance directives. Additionally, the facility was unable to provide an advance directive policy when requested.