Failure to Provide Advanced Directive Information to Resident's Representative
Penalty
Summary
The facility failed to provide an advanced directive or information about advanced directives to the responsible party for one resident. Upon admission, the resident had diagnoses including schizoaffective disorder, developmental delay, and was recovering from colostomy surgery. The Minimum Data Set indicated the resident had severely impaired cognition and was taking antipsychotic and antianxiety medications. A review of the resident's medical records showed there was no documentation of an advanced directive or any planning related to it. Interviews with the Social Services Director (SSD) revealed that while the SSD contacted the resident's Regional Center Service Coordinator (RCSC) to request other medical forms, she did not inquire about or provide information regarding advanced directives. The RCSC confirmed that the facility did not ask about an existing advanced directive or provide information about advanced directive planning. The facility's policy requires that residents or their representatives receive written information about advanced directives upon admission, and that this information be documented in the medical record, but this was not followed in this case.