Failure to Assist and Document Follow-Up on Advanced Directives
Penalty
Summary
The facility failed to ensure that residents and/or their representatives received appropriate assistance and follow-up regarding the completion of advanced directives, as required by facility policy. For five out of seven residents reviewed, documentation was lacking to show that staff offered or followed up on assistance to complete advanced directives or to ensure that residents' wishes regarding the right to accept or refuse medical or surgical treatment were addressed. In several cases, residents indicated they did not have an advanced directive and either planned to look into it or had a family member working on it, but there was no evidence in the medical record of further follow-up or documentation of outcomes. One resident with cognitive impairment and a listed representative declined to have an advanced directive, but there was no documentation that the representative was followed up with regarding the resident's rights. In other cases, residents or their families stated they would provide or were working on the necessary documents, but the clinical records did not reflect any follow-up or confirmation of completion. Interviews with facility staff, including the Social Services Director and Licensed Social Worker, confirmed the absence of documented notes or evidence of follow-up actions related to advanced directives for these residents.