Failure to Provide Advance Directive Information and Documentation
Penalty
Summary
The facility failed to provide information to residents regarding their right to formulate an advance directive, as required by both facility policy and federal regulations. Policy review indicated that residents or their representatives should be given written information about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive, either prior to or upon admission. However, for 13 out of 25 residents reviewed, there was no documentation that this information or education was provided. This included both cognitively intact residents and those with severe cognitive impairment, where representatives should have been informed. Medical record reviews for these residents revealed a consistent lack of documentation regarding whether advance directives existed or if residents or their representatives had been offered the opportunity to formulate one. In several cases, residents were cognitively intact and capable of making their own decisions, yet there was no evidence that they were informed of their rights. For residents with severe cognitive impairment, there was no documentation that their legal representatives were educated or given the opportunity to formulate an advance directive on their behalf. During interviews, facility staff, including the Administrator in Training and the Social Worker, confirmed that the forms used for advance directives were incomplete and lacked necessary information. They were unable to provide evidence of what education was given, whether residents or family members had signed or initialed forms, or whether residents had been offered, declined, or assisted with advance directives. This lack of documentation and incomplete process led to the deficiency cited by surveyors.