Failure to Inform and Document Advance Directive Options for Residents
Penalty
Summary
The facility failed to inform and provide written information to residents regarding their right to formulate an advance directive upon admission, as required. For three residents reviewed, there was no documentation that they were offered or declined the opportunity to establish an advance directive, such as a living will or durable power of attorney (POA) for health care. Specifically, one resident was cognitively moderately impaired at admission and was documented as their own responsible party, but neither the resident nor their family was provided information about establishing a POA until well after admission. Another resident, who was cognitively intact, had no documentation in their electronic health record of being offered or declining an advance directive, and only received POA paperwork after the issue was raised during the survey. A third resident, also cognitively intact, similarly had no documentation of being offered the opportunity to formulate an advance directive. Interviews with social services staff and administration confirmed that the process for offering and documenting advance directives was not consistently followed. Staff acknowledged that advance directives should be reviewed on admission and care planned, but admitted that documentation was lacking and that residents who were their own decision makers were not always offered the right to formulate an advance directive. Residents interviewed indicated they had not been approached about designating a decision maker in the event of incapacity, and expressed interest in doing so when the process was explained to them.