Failure to Ensure Advance Directive Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that a resident had an advance directive in place or that the resident’s wishes regarding advance directives were properly documented and communicated. The resident, who was admitted and later readmitted with diagnoses including metabolic encephalopathy, cerebral infarction, and moderate intellectual disabilities, was found to have limited capacity to consent and was severely cognitively impaired. Documentation from the care conference indicated the resident did not have an advance directive and did not wish to formulate one, but there was no evidence that the responsible party or legal representative was involved in this decision-making process, despite the resident’s impaired capacity. Interviews with facility staff revealed that the Discharge Planner did not verify the existence of an advance directive upon admission or readmission, nor did she document follow-up with the Regional Center or notify the physician of the resident’s advance directive status. The Director of Nursing confirmed that the facility’s policy required inquiry about advance directives prior to or upon admission, but this was not followed. As a result, the resident was considered full code by default, and the facility did not have documentation to support the resident’s or representative’s wishes regarding end-of-life care.