Failure to Inform and Document Advance Directives for Residents
Penalty
Summary
The facility failed to inform and provide written information to residents regarding their right to formulate an advance directive. For two of three residents reviewed, there was no documentation in the electronic health record (EHR) of an advance directive or evidence that the facility had offered the opportunity to formulate one. One resident was admitted with severe cognitive impairment, and staff could not locate any documentation of a power of attorney (POA) or advance directive in the EHR or social work evaluation. Staff interviews confirmed that this information was not present or documented for this resident. Another resident, who was cognitively intact at admission, also had no documentation of an advance directive or that the opportunity to formulate one had been offered. Staff reviewed the EHR and found only a POLST (Portable Orders for Life Sustaining Treatment) documented under advance directive, but clarified that a POLST does not count as an advance directive. The Director of Nursing Services confirmed that the lack of documentation for both residents did not meet facility expectations.