Failure to Document Advance Directive Discussions and Properly Complete Forms
Penalty
Summary
Facility staff failed to maintain complete and accurate clinical records for 21 of 24 sampled residents, specifically regarding documentation of advance directives and related communications. In multiple cases, staff did not document verbal communication with residents or their representatives about the reasons for refusing treatments such as oral suction and oxygen, as indicated on advance directive forms. Additionally, there was no documentation that education was provided to residents or their representatives about the consequences or potential outcomes of refusing these treatments, despite facility policy requiring such documentation. For example, one resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia, had an advance directive indicating refusal of oral suction and oxygen. However, there was no evidence in the clinical record of staff assessment or documentation of the reasons for this refusal, nor of any education provided to the resident or representative about the implications of these choices. Similar deficiencies were found for other residents, including those who were cognitively intact, where staff failed to document the required discussions and education related to advance directive decisions. Furthermore, the facility staff did not ensure that advance directive forms were completed according to the form's instructions. Instead of having the individual providing the information initial the desired areas, staff marked the forms with checkmarks or Xs. This failure to follow documentation procedures was identified for 21 residents. These deficiencies were confirmed through interviews with residents, family members, and staff, as well as reviews of clinical records and facility policies.