Failure to Provide Advance Directive Information to Resident Representative
Penalty
Summary
A deficiency was identified when a resident's medical record was reviewed and it was found that, although a surrogate had been selected on the Maryland Orders for Life Sustaining Treatment (MOLST) form and two certifications of incapacity were present, there was no documentation that the resident's representative had been provided with written information or offered the opportunity to formulate an advance directive upon admission. The review of the hard chart and medical record did not reveal any evidence that information regarding advance directives was given or discussed with the resident's representative at the time of admission, nor was there documentation of any existing advance directive. The deficiency was confirmed through interviews and record reviews, including a discussion with the DON, who was unable to locate any documentation that the advance directive process had been followed for this resident. The lack of documentation indicated that the facility failed to ensure the resident representative was informed and given the opportunity to create or provide an advance directive as required.