Failure to Provide Advance Directive Information and Assistance
Penalty
Summary
The facility failed to provide written information and offer assistance in formulating Advance Directives (AD) to two residents or their representatives, as required by facility policy. For one resident with severe cognitive impairment and no capacity to make decisions, there was no documented evidence that the resident's representative was offered the opportunity to formulate an AD upon admission or during the baseline care planning period. The medical records director confirmed this omission during a review and interview. For another resident, who had the capacity to make decisions, there was also no documentation that the resident or their representative was offered education or assistance regarding ADs within the required timeframe after admission. The case manager and MDS coordinator both confirmed that this step was missed. Facility policies reviewed indicated that such information and assistance should be provided upon admission and documented in the medical record, but this was not done for either resident.