Failure to Document Advance Directives for Multiple Residents
Penalty
Summary
The facility failed to ensure that three residents had properly documented advance directives upon admission or readmission, as required by facility policy and federal regulations. For one resident with quadriplegia and dementia, the admission record showed readmission, but the advance directive acknowledgment (ADA) form was incomplete, lacking the necessary signatures from the resident or their representative. The resident was determined to lack decision-making capacity, and staff interviews confirmed that the ADA was not official without the required signatures. The facility's policy required that advance directives be completed and included in the medical record upon admission and readmission, but this was not done for this resident. Another resident with vascular dementia and metabolic encephalopathy was admitted without an advance directive. The resident was found to be unable to make medical decisions and had no family or friends to act as a representative. The social services director stated that the interdisciplinary team (IDT) could make decisions for the resident per facility policy and had applied for a conservator. However, the process was ongoing, and the resident remained without a documented advance directive. Staff interviews indicated that, in the absence of an advance directive, the resident would be considered a full code, but the facility did not know the resident's wishes. A third resident with dementia and a history of mental and behavioral disorders was also found to lack a completed advance directive. The resident's responsible party was identified, but the ADA form was not signed by the resident or their representative, only by the physician. Key sections of the ADA form were left blank, including those indicating that the resident or representative had been informed of their rights regarding medical treatment and advance directives. Staff confirmed that the ADA was incomplete and should have been filled out upon readmission, as required by facility policy. These failures resulted in the facility not having documentation of the residents' wishes regarding medical treatment and end-of-life care.