Failure to Ensure Advance Directive Documentation and Resident Rights
Penalty
Summary
The facility failed to ensure the right of residents to request, refuse, or discontinue treatment and to formulate an advance directive for two residents. For both individuals, their medical records did not contain current copies of their advance directives, nor was there documentation of discussions regarding advance care planning, aside from code status. The facility's policy requires that, upon admission, staff determine if a resident has an advance directive, provide information about advance directives, and document any discussions or refusals. However, these steps were not consistently followed for the residents in question. For one resident, there was no evidence in the record of an advance directive or documentation of a discussion about advance care planning options. Interviews with the Social Services Director (SSD) and Social Worker (SW) revealed that while the resident had been asked about Power of Attorney documents, he wanted to consult with family before making decisions, and there was no established process to ensure follow-up or documentation, especially for residents transitioning from short-term to long-term care. The SW only addressed the issue after being prompted by the SSD due to the surveyor's inquiry, indicating the process was reactive rather than proactive. For the second resident, the record also lacked evidence of an advance directive or documentation of a discussion. The SSD was aware that the resident had an advance directive, but the document had not been obtained, despite the resident's lengthy stay. The Nursing Home Administrator confirmed that the Social Worker is responsible for obtaining and documenting advance directives, but acknowledged that follow-up was inconsistent and sometimes reliant on access to hospital records or waiting for family members to provide documents. The lack of timely documentation and follow-up led to the deficiency.