Failure to Provide and Document Follow-Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents' rights regarding advance directives (ADs) were fully honored and documented for five of seven residents reviewed. Multiple residents, including those with intact or moderate cognitive function, expressed uncertainty about whether they had an AD or requested more information about formulating one. Despite this, there was no documented evidence that these residents or their resident representatives (RPs) were provided with follow-up information or education about their right to formulate an AD after admission. Record reviews for each resident showed that, upon admission, residents were provided with an acknowledgment form regarding ADs, and if they did not have an AD, they were to be given a handout and education on how to create one. The facility's policy also required quarterly follow-up during care conferences for residents without an AD. However, for all five residents cited, there was no documentation that such follow-up or education occurred during the relevant care conferences, even when residents indicated a desire for more information or were unsure about their AD status. Interviews with the Social Services Director (SSD) confirmed that the expected process was not consistently documented or followed. The SSD acknowledged that if there was no AD on file, there was a potential for the facility to be unable to honor residents' wishes for care. The lack of documentation and follow-up regarding ADs was observed across multiple residents with varying medical conditions, including stroke, chronic obstructive pulmonary disease, diabetes, hypertensive heart disease, major depressive disorder, chronic kidney disease, and malnutrition.