Failure to Inform Resident of Advance Directive Rights and Provide Assistance
Penalty
Summary
The facility failed to ensure that a resident was informed of their right to formulate an advance directive (AD) and was provided assistance to do so, as required by facility policy. A review of the resident's clinical record showed no documentation that the resident had been informed about ADs or offered help in creating one. This was confirmed by an LPN in Medical Records, who verified that the resident's entire chart had been scanned into the electronic health record and contained no such documentation. The facility's policy requires informing residents about their rights regarding ADs and providing written information and assistance if requested. Further review revealed that the resident had been admitted several years prior with a diagnosis of unspecified dementia but was currently cognitively intact, as indicated by a BIMS score of 15 on the most recent MDS assessment. During a recent care plan conference, it was identified that the resident had no Power of Attorney or AD in place, and the Administrator confirmed that no steps had been taken since that time to inform the resident of their rights or offer assistance in formulating an AD.