Failure to Complete and Follow Up on Advance Directives for Resident with Severe Cognitive Impairment
Penalty
Summary
The facility failed to ensure that the Advance Directives process was completed and followed up for one resident with severe cognitive impairment. The resident was admitted with multiple complex medical diagnoses, including vascular dementia, bipolar disorder, and schizophrenia, and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. The care plan and physician orders indicated a full code status, but the Physician Orders for Life-Sustaining Treatment (POLST) form in the electronic health record was left blank and unsigned. Interviews revealed that the resident's family had not been contacted regarding Advance Directives, and the family member confirmed no communication from the facility about this matter. The Social Services Director acknowledged that the process for obtaining Advance Directives was not completed, and only one attempt had been made to reach the family, which was not typical practice. The Director of Nursing confirmed that the expectation is for Advance Directives to be completed in a timely manner, usually within the same day, but this was not achieved for this resident.