Failure to Inform and Offer Advance Directives to Residents Upon Admission
Penalty
Summary
Six residents were identified as not having been informed of, or provided with, the option to formulate an Advance Directive (AD) upon admission or re-admission to the facility. Record reviews for these residents revealed that their medical charts did not contain any documentation of an AD, nor evidence that they had been offered the opportunity to create one. Interviews with the Medical Records Director and Operations Manager confirmed that these residents had no ADs on file and had not been given the option to establish one during the admission process, contrary to facility policy. The residents affected had significant medical conditions, including hemiplegia, atrial fibrillation, diabetes mellitus, right lower leg fracture, COPD, chronic kidney disease, congestive heart failure, degenerative nervous system disease, acute and chronic respiratory failure, chronic lymphocytic leukemia, anoxic brain damage, breast cancer history, and traumatic subdural hemorrhage. The facility's policy required that the existence of an AD be determined prior to or upon admission by inquiring with the resident or their representative, but this process was not followed for the six residents in question.