Failure to Document Advance Directives Review and Education
Penalty
Summary
The facility failed to provide documentation that advance directives (AD) were reviewed with, or information and education regarding ADs were provided to, residents and/or their responsible representatives. For two residents, medical record reviews revealed either the absence of AD documentation or lack of evidence that discussions about ADs had occurred. In one case, although a MOLST form and a Power of Attorney document were present in the chart, there was no documentation to support that AD information was provided to the resident or their representative. Interviews with the Director of Nursing and the social work director confirmed that the required documentation was not available and that the family was being contacted to locate the AD. In another instance, a resident's medical record included a MOLST form indicating "No CPR, Option B, Palliative and Supportive Care," but no AD was found in the records, nor was there documentation of any discussion about ADs with the resident or their responsible party. Social services progress notes also lacked any mention of ADs. Staff interviews confirmed that the topic of ADs had not been addressed with the resident or their representative, and the facility's policy requiring inquiry and documentation of ADs upon admission was not followed for these residents.