Failure to Document Advance Directive Education
Penalty
Summary
The facility failed to provide written information to a resident and/or their representative regarding the right to accept or refuse medical or surgical treatment and the opportunity to formulate an advance directive. The resident, who was admitted with diagnoses including high blood pressure and a history of stroke, was found to be cognitively intact according to a recent assessment. Review of the resident's electronic medical record showed a full code physician order, but there was no documentation indicating that education about advance directives or the opportunity to formulate one had been offered to the resident or their representative. During interviews, the resident was unable to recall receiving any education about advance directives. The facility's Administrator and Nurse Practitioner both stated that education had been provided to the resident's representative via a phone call, but acknowledged that this conversation was not documented in the medical record. Attempts to contact the resident's representative for confirmation were unsuccessful.