Failure to Provide and Document Advance Directive Information for Multiple Residents
Penalty
Summary
Facility staff failed to ensure that multiple residents were provided with the opportunity to formulate, review, or discuss advance directives upon admission or during their stay. Several residents with significant medical histories, including conditions such as peripheral vascular disease, respiratory failure, congestive heart failure, diabetes, atrial fibrillation, and dementia, were not given clear information or the chance to express their wishes regarding advance directives. In some cases, documentation of advance directive discussions was missing, incomplete, or not witnessed, and residents reported that no one had reviewed the information with them prior to their signatures being obtained. For example, one resident with chronic illnesses was listed as their own responsible party and had a form marked as declined, but when interviewed, indicated that no one had explained advance directive information before the form was signed. Another resident, who was alert and oriented, had a DNR order and a signed advance directive form, but also stated that the facility staff had not reviewed advance directive information with them upon admission. In both cases, the forms lacked witness signatures, and there was no evidence in the clinical record that the required discussions had taken place. Additionally, a resident with a DDNR order had an incomplete form, with required sections left unchecked, and other residents with cognitive capacity were not provided with or did not recall receiving information about advance directives. Facility policy required that advance directive information be provided and discussed upon admission, but documentation and resident interviews revealed that this process was not consistently followed. These deficiencies were identified through clinical record reviews, resident and staff interviews, and examination of facility policies.