Failure to Offer, Obtain, and Document Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to offer, obtain, and complete advance directives (ADs) for 10 out of 26 sampled residents. During interviews and record reviews, the Assistant Director of Nursing (ADON) was unable to provide documentation that AD information was offered or that an AD had been completed for several residents. In each case, the ADON confirmed that the residents did not have an AD on file, and there was no evidence that the facility had provided the required information or assistance regarding ADs. For some residents who indicated on their admission questionnaires that they had executed an AD, the Social Services Director (SSD) was unable to provide a copy of the AD in the residents' charts. There was also no documentation that staff had followed up with these residents to obtain a copy of their ADs. In interviews, residents confirmed that the facility had not requested a copy of their ADs or provided additional information about executing one, despite their expressed interest or indication of having an AD. A review of the facility's policy and procedure on advance directives revealed that staff are required to inquire about the existence of ADs upon admission, provide written information about the right to formulate an AD, and assist residents in establishing one if needed. The policy also requires that copies of executed ADs be maintained in the resident's medical record and be readily retrievable by staff. The facility did not follow these procedures for the affected residents.