Failure to Offer Advance Directive Information to Residents
Penalty
Summary
The facility failed to ensure that residents were offered the opportunity to create an advance directive, as required by its own policy. Record review and interviews revealed that two residents, out of a sample of three reviewed for advance directives, did not have documentation in their electronic health records indicating that advance directive information had been provided. The facility's policy states that upon admission, residents must be given written information about their rights regarding advance directives and that this information should be prominently displayed in the medical record. However, for these two residents, there was no evidence that such information was provided or documented, and the MDS coordinator confirmed that no advance directives were on file for them.