Failure to Ensure Advance Directives Are Documented and Residents Are Educated
Penalty
Summary
The facility failed to ensure that residents' rights regarding advance directives (AD) were honored for two of six residents reviewed. For one resident with aphasia following a non-traumatic intracerebral hemorrhage, although an advance directive was executed upon admission, a copy of the AD was not available in the resident's record. The Social Services Director (SSD) confirmed that the AD should have been accessible in the record for nurses and physicians to reference, especially in situations where the resident is unconscious. The absence of the AD in the record could result in care being provided that does not align with the resident's wishes. For another resident with fluctuating capacity to understand and make decisions, there was no documentation that the resident or their representative had been provided with information or education regarding the formulation of an AD. The resident was unaware of what an AD was, and the SSD acknowledged that neither education nor a review for AD had been conducted for this resident. The facility's policy requires staff to inquire about the existence of an AD and to offer assistance and document the resident's decision, but this process was not followed.