Failure to Assist Resident with Advance Directive Completion
Penalty
Summary
The facility failed to follow up on a resident's request to formulate an Advance Directive, resulting in a delay of seven years in addressing the resident's wishes. The resident, who had a diagnosis of malignant neoplasm of the right breast and blindness in one eye, was cognitively intact and required assistance with several activities of daily living. Upon admission and during subsequent care plan meetings, the resident expressed a desire to execute an Advance Directive but needed help completing the form due to her visual impairment. Despite these requests, the necessary assistance was not provided. Documentation in the resident's records, including the Minimum Data Set and care plan, indicated that the resident was capable of making her own decisions and had specifically requested CPR in the event of an emergency but did not want to be transferred to a hospital. The Social Services Worker acknowledged the resident's request but failed to communicate with the Ombudsman, who could have assisted in completing and witnessing the Advance Directive. The Social Services Worker incorrectly believed that the lack of a designated decision-maker, such as a child, prevented the resident from completing the document, and did not take further action. Interviews with facility staff, including the Director of Nursing and the Administrator, confirmed that the resident was eligible to complete an Advance Directive and that the facility's policy required staff to offer assistance in establishing such directives. The policy also required regular review of advance directives and documentation of offers to assist residents. However, these procedures were not followed in this case, resulting in the resident's wishes not being formally documented for an extended period.