Failure to Inform Resident or Responsible Party of Advance Directive Rights
Penalty
Summary
The facility failed to inform a resident and/or their Responsible Party (RP) of the right to accept or refuse medical or surgical treatment and to formulate an advance directive. The resident in question was admitted with a legal guardian as RP and had a physician order indicating full code status. The social service history and initial assessment form, which included an advanced care planning section, was not completed at the time of admission. The resident's quarterly MDS assessment indicated moderate cognitive impairment, making it especially important for the RP to be informed of these rights. A review of the medical record showed no documentation that the resident or RP was informed of the right to refuse treatment or to create an advance directive. The Social Worker (SW) stated that she typically discussed advance directives during admission but had only attempted to contact the RP by phone and had not sent a certified letter after unsuccessful attempts. The SW eventually reached the RP and discussed advance care planning, but this occurred well after admission and was not documented in a timely manner. Both the DON and Administrator confirmed that the SW should have followed up and ensured the discussion and documentation took place as part of the admission process.