Failure to Document Advance Directives Education and Resident Decisions
Penalty
Summary
The facility failed to document advance directives education and the decisions regarding advance directives for seven residents, as required by its own policy. The policy states that upon or prior to admission, the social services director or designee must inquire about the existence of any written advance directives, provide written information to the resident or representative, and ensure that information about whether or not the resident has executed an advance directive is displayed prominently in the medical record. However, for all seven residents reviewed, there was no written documentation that advance directive education was discussed or provided, nor was there any record of the residents' decisions regarding advance care planning, living wills, or power of attorney. The residents involved had a range of medical conditions, including schizoaffective disorder, mood disorder, psychotic disorder, dementia, chronic kidney disease, Parkinson's disease, obstructive and reflux uropathy, atrial fibrillation, depression, stroke, hypertension, diabetes, cancer, and fractures. Their cognitive status varied, with some residents being cognitively intact and others having moderate to severe cognitive impairment, as indicated by their BIMS scores. Despite these differences, the lack of documentation was consistent across all cases reviewed. During a record review and interview, the Social Services Director confirmed that there was no documentation in the medical records to indicate that the residents had received and understood advance directive education or that their decisions regarding advance directives had been recorded. This failure was identified through facility policy review, medical record review, and staff interview, and affected all seven residents reviewed for advance directives.