Failure to Offer Opportunity to Formulate Advance Directives
Penalty
Summary
Three residents who were cognitively intact upon admission were not offered the opportunity to formulate an advance directive. Clinical record reviews showed that, although social history assessments documented code status and the presence of a general power of attorney, there was no documentation indicating that the residents were asked about existing advance directives or given the chance to create one. The assessments failed to address whether the residents had or wished to establish an advance directive. Interviews with facility staff, including the clinical liaison and an LPN, confirmed that the admitting nurse is responsible for reviewing admission documents and completing resident assessments. The NHA and DON stated that the physician would discuss advanced care options with residents during an exam, but there was no evidence in the records that this discussion or offer occurred. The lack of documentation and confirmation from staff interviews indicated that the facility did not provide the required opportunity for these residents to formulate advance directives.