Failure to Ensure Advance Directives Were Offered and Documented
Penalty
Summary
Surveyors found that the facility failed to offer or ensure that advance directives were on file for six sampled residents. Record reviews showed that while some residents had executed advance directives, these documents were not consistently present in either the paper charts or electronic health records. For several residents, there was no evidence that they had been offered the opportunity to complete an advance directive or that staff had assisted them in locating or completing one. The facility's own policy requires staff to inquire about advance directives during admission, document their existence, and include copies in the medical record, but this process was not followed for the residents reviewed. The residents involved had a range of significant medical conditions, including epilepsy, schizophrenia, stroke, atherosclerosis, traumatic subdural hemorrhage, venous insufficiency, and adult failure to thrive. Despite these complex health needs, the facility did not ensure that advance directives were available or that residents were informed about their right to execute one. During interviews, facility staff acknowledged the importance of having advance directives on file, especially in emergency situations when residents may become incapacitated, but confirmed that the required documentation and offers were not consistently made.