Failure to Provide Written Advance Directive Information and Assistance
Penalty
Summary
Facility staff failed to provide written information regarding the right to formulate an advance directive to 11 out of 30 sampled residents. Clinical record reviews showed that these residents had signed an acknowledgment of receipt of admission information, which included a reference to an 'Advance Directive Handbook.' However, interviews with the administrator revealed that no such handbook existed, and there was no evidence that advance directive education had been provided to the residents. The administrator also confirmed that the facility did not currently offer assistance to residents in formulating advance directives, despite this being referenced in the facility's policy. The facility's own Advance Directive policy requires that residents be given written information about their rights to accept or refuse medical or surgical treatment and to formulate an advance directive, as well as a description of the facility's policies and applicable state law. The policy also states that staff should offer assistance in establishing advance directives and document the offer and the resident's decision in the medical record. No documentation or evidence was found to show that these requirements were met for the affected residents.