Failure to Provide Advance Directive Education and Documentation
Penalty
Summary
The facility failed to provide education and written information regarding advance directives to residents and/or their representatives, as required by policy. Policy review indicated that the social services director or designee is responsible for inquiring about the existence of advance directives and providing written information to residents or their representatives prior to or upon admission. However, for 27 out of 35 sampled residents, there was no completed documentation in the medical records to show that this education or information was provided. The deficiency was identified through a combination of policy review, medical record review, and staff interview. Medical records for the affected residents, who had a range of diagnoses including diabetes, dementia, chronic respiratory failure, anoxic brain injury, and other serious conditions, consistently lacked documentation of advance directive education. The cognitive status of these residents varied, with some being severely cognitively impaired, some moderately impaired, and others cognitively intact, as indicated by their BIMS scores or clinical assessments. Regardless of cognitive status, the required documentation was missing for all identified residents. During an interview, the Marketing Director confirmed that there was no process in place for educating residents or their representatives about advance directives prior to the week before the survey. This lack of process contributed to the widespread absence of documentation and failure to meet the facility's policy and regulatory requirements regarding residents' rights to formulate advance directives.