Failure to Honor Resident's Right to Formulate Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's right to formulate an advance directive was honored. The resident in question was admitted without Power of Attorney (POA) or guardianship documentation and was listed as his own responsible party. Despite being moderately cognitively impaired, he was alert and oriented for much of the day, as confirmed by staff and social service notes. The resident's medical record showed that he was able to participate in meaningful conversations and expressed a desire to get better, indicating an understanding of his condition and the ability to make his own healthcare decisions. Documentation revealed that a notary was scheduled to assist the resident in establishing a healthcare POA, and discussions about changing his code status were held with his son. The Medical Power of Attorney document was signed by both the resident and his son, but the section regarding when the agent's authority would become effective was left blank and not initialed by the resident. The POST form, which outlined the resident's code status, was signed by the son rather than the resident, and there was no documentation from a physician determining that the resident was incompetent to make his own decisions at that time. Interviews with staff and documentation in the medical record indicated that the resident was capable of making his own healthcare decisions, particularly during the day. However, decisions regarding his code status and comfort measures were made by his son without clear evidence that the resident was unable to participate or that a physician had declared him incompetent. Facility policy requires that residents make their own decisions if they have capacity, and that a physician's assessment of incapacity be documented before a representative or POA acts on their behalf. This process was not followed, resulting in a failure to honor the resident's right to formulate and participate in decisions regarding advance directives.