Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to provide or document the provision of written information regarding the right to formulate an advance directive to residents and/or their representatives. Record reviews for 13 out of 14 residents revealed no evidence that such information was offered, reviewed, or provided at the time of admission or thereafter. This deficiency was confirmed through interviews with the Clinical Reimbursement Manager and the Social Services Assistant, both of whom acknowledged the absence of documentation and the lack of discussion or provision of advance directive information. The Social Services Assistant further stated she did not know what an advance directive includes beyond cardiopulmonary resuscitation (CPR). The affected residents were admitted over a span of several years, and both electronic and paper medical records were reviewed for evidence of compliance. In each case, there was no documentation that residents or their representatives were asked to provide a copy of their advance directives, nor were they given information or assistance to formulate one if they did not have it. The deficiency was identified through both record review and staff interviews, with staff confirming the lack of process and understanding regarding advance directives.