Failure to Determine Advance Directive Status and Identify Decision Maker
Penalty
Summary
Facility staff failed to determine on admission whether a resident had an advance directive and did not provide information about the right to formulate one. The admission record for the resident showed the section for advance directives was left blank, and there was no documentation indicating that staff had informed the resident of their rights or offered assistance in establishing an advance directive. The resident was noted as being cognitively intact at admission, with a BIMS score of 14, and was listed as their own responsible party. Subsequently, the resident experienced increased confusion and was assessed by two physicians, who determined that the resident lacked capacity to make informed medical decisions. Despite this change in condition, the medical record did not identify who was responsible for making decisions on the resident's behalf or how a surrogate decision maker was determined. When requested, the facility administrator was unable to provide documentation regarding advance directives or the identification of a decision maker for the resident.