Failure to Assist with Advance Directive Formulation
Penalty
Summary
The facility failed to ensure that a resident and their representative were provided with assistance to exercise the right to formulate an Advance Directive. Upon review of the medical record for a resident admitted with anoxic brain damage and quadriplegia, it was found that while the record included a POST and a Letter of Guardianship, there was no documentation of an Advance Directive. Additionally, there was no evidence that the facility had offered to assist the resident's guardian in formulating an Advance Directive, as required by regulation. Interviews with the Director of Nursing and the Administrator confirmed that the resident had not created an Advance Directive prior to admission, and the guardian had not completed one either. Furthermore, the resident's record did not contain documentation that Advance Directive information had been offered to the guardian. This lack of documentation and assistance constituted a failure to comply with federal requirements regarding advance care planning.