Failure to Ensure Residents' Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that residents were able to exercise their right to formulate an advance directive, as required by regulation. For two residents with multiple diagnoses including dementia, PTSD, hallucinations, and depression, there was no documentation in their records of an advance directive for healthcare. Additionally, there was no evidence that resources or assistance were offered to help these residents execute an advance directive. Staff interviews confirmed that the facility's focus during care conferences was on the POLST form, and discussions about advance directives were not conducted. In one case, a resident's sister facilitated admission and signed a financial power of attorney, but the resident did not sign a healthcare power of attorney, and there was no follow-up documented regarding advance directive options. In the other case, there was no documentation that information or assistance with advance directives was offered to the resident's legal guardian.