Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide a resident and/or their representative with written information regarding the right to accept or refuse medical or surgical treatment and to formulate an advance directive. According to the facility's policy, staff are required to determine if a resident has an advance directive upon admission and, if not, to offer information about the right to create one. The policy also states that any decisions regarding the resident's choices should be documented in the medical record and communicated to the care team. However, the policy did not specify that this information must be provided in written form. Record review for one resident revealed no documentation that written information about advance directives or the right to accept or refuse treatment was provided at admission or re-admission. During an interview, the DON confirmed that there was no record of the resident receiving any information about advance directives, as the admission occurred under previous ownership and no documentation was available in the electronic medical record.