Failure to Timely Obtain and Document Advance Directive
Penalty
Summary
The facility failed to have a signed advance directive for one resident out of eight sampled, despite requirements to inform and provide written information to all adult residents regarding their right to formulate an advance directive. The resident in question had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had expressed that preferences for customary routine activities were important. Upon admission, the resident was experiencing adjustment issues, and interventions were in place to support their preferences and autonomy. However, a review of the resident's records, including the Minimum Data Set, care plan, clinical census, and electronic medical record, revealed no documentation of an advance directive or code status at the time of review. Further investigation showed that the facility's policy required communication of code status and adherence to residents' rights regarding advance directives. Despite this, the advanced directive for the resident was not present in the medical record and was only located later in the social service office, with documentation indicating it was received and dated after the initial record review. Interviews with facility staff confirmed the delay in obtaining and filing the advance directive, indicating a lapse in ensuring that the resident's rights regarding advance directives were honored in a timely manner.