Failure to Provide Advance Directive Information to Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide a resident with information regarding the right to formulate an advance directive. Upon admission, the resident, who had diagnoses including diffuse traumatic brain injury, bipolar disorder, anxiety disorder, and unspecified dementia, was identified as having severe cognitive impairment with a BIMS score of three. The facility did not have any documentation of advance directives, such as Power of Attorney paperwork, Guardian paperwork, or a POLST form, for this resident. The only documentation present was a physician's order indicating full code status, which the Director of Social Services acknowledged is not a valid advance directive. Interviews revealed that no discussion regarding advance directives took place with the resident due to their low cognitive status and lack of decisional capacity. The facility's policy requires that upon admission, the resident's decision-making capacity be determined, the primary decision maker identified, and existing choices reviewed with the resident or legal representative. However, this process was not followed, and no care plan was developed regarding advance directives for the resident, resulting in a failure to honor the resident's rights as outlined in facility policy.