Failure to Provide Advance Directive Information to Cognitively Intact Resident
Penalty
Summary
The facility failed to provide a cognitively intact resident with information and opportunities to formulate an advance directive. Upon review of the resident's medical record, there was no evidence of an advance directive or documentation that information or materials regarding advance directives had been offered. The Social Services Assessment and Documentation for the resident indicated that no conversation or materials related to advanced care planning were provided, and all relevant questions were answered in the negative. During interviews, the Social Services Director confirmed that the resident did not have an advance directive in place and that there was no documentation showing that information or opportunities to complete one had been provided. The resident was responsible for making their own medical decisions, and there was no durable power of attorney for healthcare on file. The lack of documentation and provision of information was acknowledged by the Social Services Director during the survey.