Failure to Document Advance Directive Discussions for Two Residents
Penalty
Summary
The facility failed to ensure that the medical records of two sampled residents were updated to show documented evidence that advance directives (AD) were discussed, as required by policy and regulation. For one resident, the admission record indicated multiple diagnoses including psychosis, dementia, and muscle wasting, with conflicting assessments of cognitive capacity. The Advance Healthcare Directive Acknowledgement Form for this resident was incomplete, lacking documentation of whether the resident or their representative was provided information about formulating an AD or if they refused such information. Interviews with the LVN, Social Services Director (SSD), and Director of Nursing (DON) confirmed that the form was not properly completed and that the resident’s or representative’s right to be informed and assisted in formulating an AD was not honored. A second resident, admitted with significant cardiac and neurological diagnoses, also had an incomplete Advance Healthcare Directive Acknowledgement Form. The form did not indicate whether the resident or their representative was provided information on advance directives or whether an advance directive had been formulated prior to admission. Staff interviews confirmed that the required documentation was missing, and the SSD acknowledged that the resident’s right to formulate an advance directive was not ensured due to the lack of proper documentation and follow-through. Facility policy required that, at the time of admission, staff inquire about the execution of an advance directive and document any discussion regarding advance directives in the resident’s record, even if the resident chose not to execute one. Both the Basic Record Review and Resident Rights-Quality of Life policies emphasized the importance of documentation and person-centered care. The failure to complete and document the Advance Healthcare Directive Acknowledgement Forms for these residents resulted in a violation of their rights to be fully informed and to participate in decisions regarding their care.