Failure to Document and Discuss Advance Directives with Residents
Penalty
Summary
The facility failed to provide evidence that staff discussed advance directives with two residents, as required by policy. For one resident with diagnoses including acute respiratory failure with hypoxia, cirrhosis of the liver, major depressive disorder, and tracheostomy status, there was no documentation in the electronic health record regarding whether the resident had an existing advance directive or had been informed of the right to formulate one. Additionally, the section of the resident's Physician’s Order for Life Sustaining Treatment (POLST) form regarding advance directives was left blank. The Corporate Medical Records Resource confirmed the absence of documentation and acknowledged the incomplete POLST form. For another resident admitted with traumatic hemorrhage of the cerebrum and chronic respiratory failure with hypoxia, the clinical record also lacked documentation that the resident or their representative was offered assistance to accept or decline the establishment of an advance directive. The Interim Director of Nursing reviewed the record and confirmed that the facility’s policy, which requires staff to offer assistance and document the resident’s decision regarding advance directives, was not followed in this case.