Failure to Provide and Document Advance Directive Information for Residents
Penalty
Summary
The facility failed to provide written information regarding the right to formulate advance healthcare directives for two residents, as required by its own policies and procedures. For one resident, the medical record did not contain evidence that written information about advance directives was provided upon admission, despite documentation indicating the resident had executed an advance directive. The case manager, responsible for gathering advance directives, was unable to produce documentation of discussions or provision of information regarding advance directives for this resident, and the required staff signature was missing from the acknowledgment form. For another resident, who was readmitted with severe cognitive impairment as indicated by a BIMS score of zero, the medical record showed an incomplete POLST form and an acknowledgment that the resident wished to execute an advance directive. However, there was no documentation that resources or follow-up were provided to the resident's family member, and no advance directive was available in the medical record. The social services designee confirmed that the process and resources provided for executing an advance directive must be documented, and acknowledged that this was not done. Interviews with facility staff, including the case manager, director of staff development, social services designee, and DON, confirmed that the expected processes for providing information, documenting discussions, and assisting with advance directives were not followed or documented for these residents. The lack of documentation and incomplete forms were verified by staff during the survey.