Failure to Provide Advance Directive Information at Admission
Penalty
Summary
The facility failed to ensure that residents were provided with written information regarding their right to formulate an advance directive upon admission. Record review for two residents showed no documentation of advance directives or evidence that information about their rights to establish one was given at the time of admission. The surveyor was unable to locate any documentation verifying that the required information was presented to the residents, and the Director of Nursing (DON) was also unable to provide signed documentation confirming this. Although there were notes indicating that the social worker addressed the status of advance directives and that responsible parties were contacted after admission, there was no evidence that the residents themselves received the necessary information upon admission. The deficiency was identified through review of electronic medical records and interviews with facility staff, which confirmed the lack of required documentation.