Failure to Provide Advance Directive Information to Resident and Representative
Penalty
Summary
The facility failed to provide a resident and their representative with information regarding the formulation of an advance directive. Upon review of the resident's admission record, it was found that there was no documented evidence that the resident had completed an advance directive or that the facility had provided the necessary information or assistance to the resident or their representative about creating one. This was confirmed during an interview and record review with a registered nurse, who acknowledged the absence of documentation and information provided. The resident in question had a history of chronic respiratory failure and sepsis, and was assessed as having severely impaired cognition, being totally dependent on staff for activities of daily living. The facility's own policy, last reviewed in January 2025, states that residents have the right to formulate an advance directive. However, the lack of documentation and failure to provide information to the resident or their representative constituted a violation of this right.