Failure to Document Provision of Advance Directive Information
Penalty
Summary
Facility staff failed to provide documented evidence that information regarding the right to formulate or refuse an advance directive was given to five sampled residents or their representatives. The facility's policy requires that upon admission, residents or their legal representatives receive written information about their rights concerning medical treatment and advance directives, and that this information be clearly documented in the medical record. However, for the five residents reviewed, there was no such documentation present in their records. The residents involved had significant medical conditions, including encephalopathy, chronic respiratory failure, ALS, interstitial pulmonary disease, anoxic brain injury, and diabetes. In each case, the medical records included care plans referencing end-of-life wishes and interventions such as offering the facility's advance directive form (5 Wishes) quarterly. Despite these care plan entries, there was no evidence that the required information about advance directives was actually provided to the residents or their responsible parties, nor was there documentation of any follow-up if the forms were not completed. During staff interviews, the Director of Social Services confirmed that the practice was to leave the advance directive form in the resident's room and wait for it to be returned if completed, with no follow-up if the form was not returned. This lack of follow-up and documentation resulted in the facility's failure to demonstrate compliance with its own policy and regulatory requirements regarding advance directives.