Failure to Ensure Advance Directives Are Discussed and Documented
Penalty
Summary
Facility staff failed to ensure that advance directives were discussed with residents or their responsible representatives and did not maintain current copies of residents' advance directives in the medical records. This deficiency was identified for six residents out of forty-seven reviewed during the recertification survey. Surveyor review of the medical records for these residents did not reveal any advance directives on file. Interviews with the Unit Manager confirmed that not all residents had advance directives and that, if available, they should be located in both the paper chart and the electronic medical record (PCC). Further interviews with the Social Services Director (SSD) revealed that, while the process requires offering advance directives at admission and quarterly for LTC residents, there was no documentation of these discussions for several residents. The SSD acknowledged that for some residents, there was no record of advance directive discussions or copies in the medical record. Additionally, it was confirmed that some residents were not offered the opportunity to formulate an advance directive upon admission, and documentation of these discussions was lacking until prompted by the surveyor.