Failure to Provide Advance Directive Information and Follow-Up
Penalty
Summary
The facility failed to ensure that seven out of fourteen residents reviewed for Advance Directives (ADs) were provided with follow-up information regarding the formulation of an AD. Multiple residents, including those with the capacity to make decisions and those with fluctuating or no capacity, were either unsure if they had an AD or could not recall being offered information about one. Record reviews for these residents consistently showed either no documentation of an AD or no evidence that information or education about ADs was provided to the resident or their representative. Interviews with the Social Service Director (SSD) revealed that the facility's protocol was to determine the presence of an AD upon admission and to offer resources if one was not present. However, the SSD acknowledged that follow-up with residents or their representatives was not consistently performed, and documentation of such follow-up was lacking. In several cases, the SSD admitted that education and resources regarding ADs were not provided as required, and that quarterly reviews or care conferences did not include documented follow-up on ADs for residents without one. The facility's own policy required that residents be asked about ADs upon admission and that assistance be offered if an AD was not in place, with this information to be prominently displayed in the medical record. Despite this, the survey found that for the seven residents in question, there was no documented evidence that they or their representatives were provided with the necessary information or education about their right to formulate an AD, as required by facility policy and federal regulations.