Incomplete Advance Directive Acknowledgement for Resident with Impaired Cognition
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive Acknowledgement form was accurately completed. Upon review, the resident's admission record indicated a diagnosis of schizoaffective disorder, and the history and physical documented fluctuating capacity to understand and make decisions. The Minimum Data Set assessment showed the resident had moderately impaired cognition and required moderate assistance with activities of daily living. Despite these factors, the Advance Directive Acknowledgement form for the resident was left blank, with no indication of whether the resident had an advance directive or if they wished to formulate one. During an interview and record review, the Social Services Director confirmed that the form was incomplete and acknowledged that the resident had not been given the opportunity to discuss or formulate an advance directive. The facility's policy requires that, upon admission, staff determine if a resident has an advance directive and, if not, offer the opportunity to create one. The failure to complete the acknowledgement form resulted in an inaccurate and incomplete record regarding the resident's preferences for end-of-life care.