Failure to Provide Advance Directive Information and Assistance
Penalty
Summary
The facility failed to provide information and assistance to formulate an advance directive for two residents reviewed for advanced directives. According to facility policy, staff are required to provide written information about advance directives to all residents or their representatives upon or immediately after admission, and to document this in the resident's record. For one resident with severe cognitive impairment and dependency on staff for all care, records indicated an interest in formulating an advance directive, but there was no documentation that information or assistance was provided. Staff interviews confirmed that the resident did not have an advance directive and that no information had been given. For another resident with severe memory impairment and a diagnosis of non-Alzheimer's dementia, records showed the resident reported having advance directive paperwork but also requested information on how to formulate one. There was no documentation that information or assistance was provided, nor was there a copy of an advance directive in the resident's records. Staff interviews confirmed the absence of documentation regarding the provision of information or assistance for both residents.