Failure to Offer and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that a resident was offered information to formulate an advance directive (AD) as required by its policy. According to the facility's policy, if a resident does not have an AD, the resident or their representative should be given the option to accept or decline assistance in establishing one, and nursing staff are required to document the offer and the resident's decision in the medical record. In the case of a resident admitted with a diagnosis of stroke, the care plan indicated that AD or POLST documentation should be present in the medical record at all times. However, the quarterly social history review noted that the resident did not have an AD, and there was no indication that AD information was offered. Further review revealed that the resident was cognitively intact and, during an interview, stated that no one had discussed ADs with them. Staff interviews confirmed that while residents are typically asked about ADs upon admission and quarterly, and blank forms are offered if needed, the new care conference form no longer included a section to document that AD information was provided. Staff acknowledged that there was no documentation in the resident's record to show that AD information had been offered.