Failure to Provide and Document Advance Directive Information and Documentation
Penalty
Summary
The facility failed to provide and document written information to residents and their representatives regarding the right to accept or refuse medical or surgical treatment and to formulate an Advance Directive, as required by federal regulations and the facility's own policies. Multiple residents, including those with severe cognitive impairment and those who were cognitively intact, did not have copies of their Advance Directives, Living Wills, or Power of Attorney (POA) documents present in their electronic medical records (EMR) when requested by surveyors. Instead, the only documentation provided was a Hospitality Guide Acknowledgement, which did not include the required Advance Directive documents. For several residents, such as those with diagnoses of cerebral palsy, epilepsy, dementia, and heart disease, the facility's records showed either a lack of documentation of Advance Directives or incomplete records, such as missing POA or Living Will documents. In some cases, residents or their representatives stated they did not recall receiving written information about Advance Directives or signing related documents. Interviews with facility staff, including the Social Services Director, Director of Medical Records, Director of Nursing, and the Administrator, confirmed that while the facility had processes in place to request Advance Directives during admission and care plan meetings, these processes were not consistently followed or documented. The facility's policies required that residents be informed of their rights regarding Advance Directives upon admission and that staff verify and periodically review these wishes. However, the survey found that for six sampled residents, there was no evidence that the facility provided the necessary written information or obtained and retained the required documentation. This deficiency was identified through interviews, record reviews, and policy reviews, demonstrating a failure to comply with federal and state requirements for Advance Directives.