Failure to Provide and Document Advance Directive Information and Follow-Up
Penalty
Summary
The facility failed to ensure that a copy of each resident's Advance Directive (AD) was available and that residents or their representatives were provided with follow-up information regarding the formulation of an AD. This deficiency was identified in 11 out of 14 residents reviewed for ADs. Multiple residents, during interviews, expressed uncertainty about whether they had an AD, whether they had been asked about creating one, or whether they had received information or follow-up on the topic. Record reviews for these residents consistently showed either the absence of an executed AD or lack of documentation that information or education about ADs was provided or followed up. For each resident cited, the admission records, Advance Directive Acknowledgment forms, POLST forms, and care conference documentation were reviewed. In all cases, the documentation either indicated that the resident had not executed an AD or did not mention an AD at all. Care conference records typically had a check mark for "Advance Directive/POLST/code status order," but there was no evidence that residents or their representatives were given information or education about their right to formulate an AD, nor was there documentation of follow-up discussions. Interviews with the Social Service Director confirmed that such documentation was missing and should have been present. Residents involved in the deficiency included those with both intact and moderately impaired cognitive function, as indicated by their BIMS scores. Several residents stated they would like to have an AD or wanted more information, while others were unsure if the facility had followed up with them. The facility's policy required that residents or their representatives be provided with written information about ADs and that staff document offers of assistance and the resident's decision. However, the required documentation and follow-up were not found in the records reviewed for the cited residents.