Failure to Inform Residents of Right to Formulate Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an advance directive, as required by policy. For 10 out of 54 residents reviewed, there was no documentation in the medical records that the facility informed or provided written information regarding the right to formulate an advance directive. In each case, the residents' records contained a POST (Physician Orders for Scope of Treatment) document, but lacked an advance directive and any evidence that the facility had communicated the option or provided the necessary information to the resident or their representative. The affected residents had a range of significant medical conditions, including coronary artery disease, GERD, anemia, atrial fibrillation, hypertension, malnutrition, non-traumatic brain dysfunction, hyperlipidemia, thyroid disorder, diabetes, PTSD, chronic kidney disease, epilepsy, aphasia, hemiparesis, dementia, heart failure, and muscle weakness. In one instance, a resident had previously revoked a POA for healthcare, but there was still no documentation of an advance directive or that information about advance directives had been provided. The facility administrator confirmed the absence of both advance directives and documentation of having informed the residents or their representatives about their rights in these cases.