Failure to Offer and Document Advance Directive Information
Penalty
Summary
The facility failed to ensure that four residents were offered information regarding Advance Directives, as required. During a record review, it was found that there was neither an Advance Directive nor documentation indicating that information about Advance Directives had been offered to these residents in their electronic medical records. When the surveyor inquired about the missing documentation, a staff member acknowledged that an audit had been started to identify residents needing Advance Directives and that outreach to residents and responsible parties had begun, but this process had not been performed consistently. The absence of both the Advance Directives and documentation of having offered the information was confirmed for the four residents reviewed.