Failure to Document and Facilitate Advance Directives for Two Residents
Penalty
Summary
The facility failed to ensure that two residents' rights to request, refuse, and/or discontinue treatment and to formulate an advance directive were honored, as required by facility policy. For both residents, their charts did not contain current copies of their advance directives or documentation of advanced care planning beyond code status. During record reviews, surveyors were unable to locate copies of the residents' advance directives or Power of Attorney for Health Care (POAHC) in the electronic medical records. Interviews with the Social Services Director confirmed that there was no documentation on file for either resident regarding their advance directives or evidence that assistance was offered or preferences were documented. In one case, documentation indicated that a resident was interested in completing advance directive documents, but there was no evidence that assistance was provided or that this interest was followed up on. The Social Services Director acknowledged that documentation should have been present to show that residents were offered assistance in completing advance directives and that their preferences were recorded. The lack of documentation and follow-up regarding advance care planning for these residents constituted a failure to comply with the facility's own policy and federal requirements.