Failure to Provide and Document Advance Directive Information and Availability
Penalty
Summary
The facility failed to ensure that advance directives (ADs) were properly documented and readily available in the records of several residents. For one resident who had executed an AD, there was no copy of the AD in either the electronic or paper chart, and the facility did not follow up with the resident's representative to obtain it. This omission was confirmed by the Social Service Director (SSD), who acknowledged that the AD should have been available and that follow-up with the family member had not occurred. Additionally, for six other residents, there was no documented evidence that written information regarding the formulation of an AD was provided to them or their representatives. These residents had various medical conditions, including acute kidney failure, cerebral vascular accident, fractures, urinary tract infection, hemiplegia, and diabetes mellitus. Some residents were cognitively intact and able to make decisions, while others had severe cognitive impairment and required information to be provided to their legal representatives. In each case, the records lacked documentation that the required information about ADs was given. During interviews, the SSD confirmed that written information about formulating an AD was not being provided to residents or their representatives, and there was no documentation to show that this requirement was being met. The facility's own policy required that residents or their legal representatives be given written information about ADs upon admission and that the existence of an AD be prominently displayed in the medical record. These requirements were not followed for the residents identified in the report.