Failure to Provide Written Information on Advance Directives
Penalty
Summary
The facility failed to inform and provide written information regarding the right to formulate an advance directive for one resident who was cognitively intact and able to verbalize their needs. Upon admission and during subsequent care conferences, there was no documentation that the resident was given written information about their right to establish an advance directive, as required by facility policy. The care plan and care conference evaluation both indicated that the resident did not have an advance directive, but did not show that the resident was informed of their rights or provided with the necessary information. Interviews with staff, including the Resident Care Manager and Social Services, confirmed that information on advance directives should have been offered and documented, but a review of the resident's medical record revealed no such documentation. The resident also stated that only their CPR status was reviewed, and they were not informed or provided with written information about advance directives. The facility's policy required this information to be provided and documented, but this was not done for the resident in question.