Failure to Provide Advance Directive Information to Residents
Penalty
Summary
The facility failed to ensure that three residents were provided with written information regarding their right to formulate an Advance Directive (AD) upon admission, as required by facility policy and federal regulations. For each of the three residents reviewed, there was no documented evidence that the AD was discussed or that the AD Acknowledgment form was completed. Interviews with the Social Services Director (SSD) and nursing staff confirmed that the process for providing and documenting this information was not followed for these residents. One resident with diagnoses including end stage renal disease, diabetes, dementia, and sepsis was admitted and re-admitted to the facility. The resident was assessed as able to understand and make decisions, but the Social Service History and Initial Assessment Form was incomplete, and there was no documentation that the AD was discussed or that written information was provided. The SSD and nursing staff confirmed that the required AD Acknowledgment form was not completed, and the facility process was not followed. A second resident with hemiplegia, hemiparesis following a stroke, and anxiety disorder, and a third resident with anxiety disorder, bipolar disorder, neuropathy, and psychosis, were both found to have the capacity to understand and make decisions. However, neither had documentation in their records that the AD was discussed or that written information was provided. The SSD and RN confirmed that the AD Acknowledgment forms were not completed for these residents, and that the facility's process for informing residents about their rights regarding ADs was not followed.