Failure to Formulate or Offer Advance Directives Upon Admission
Penalty
Summary
The facility failed to formulate or offer to formulate an advance directive for two residents upon admission, as required by policy. For one resident with severe cognitive impairment and multiple diagnoses, including dementia and metabolic encephalopathy, the admission record left the advanced directives section blank. Multiple staff members, including a registered nurse, social service assistant, and the DON, were unable to locate any documentation of an advance directive, POLST form, or code status in the resident's electronic health record or care plan. The absence of this documentation meant that staff would not know what type of care to provide in an emergency. A POLST form was later produced, but it was signed on the day of the survey, and the signature date was initially incorrect and had to be corrected in front of surveyors. For a second resident, who was mostly cognitively intact and had several chronic conditions, the care plan indicated full code status, but there was no copy of an advance directive or POLST form in the electronic health record at the time of review. The POLST form was only signed and dated after the surveyor's inquiry. Facility policy requires that residents be provided with information about advance directives upon admission, and that staff document the offer to assist and the resident's decision. In both cases, these steps were not completed as required.