Failure to Provide and Document Advance Directive Information
Penalty
Summary
The facility failed to provide written information and assistance regarding the formulation of advance directives to several residents, as required by its own policies and federal regulations. Specifically, five out of sixteen sampled residents did not receive the necessary written information or documentation about their rights to formulate an advance directive. For two residents, there was no evidence that written information or assistance was provided, and for two others, there was no documentation that the information was offered or discussed. In one case, the facility did not provide written information to a resident's representative when the resident lacked capacity. Medical record reviews revealed that documentation was missing or incomplete for these residents. For example, some residents' records did not include the Advance Directive Acknowledgment form, and progress notes failed to show that the formulation of an advance directive was offered or discussed. In cases where residents were unable to make decisions, there was no evidence that their legal representatives were provided with the required information. Interviews with the MDS Coordinator and DON confirmed these documentation gaps and acknowledged that the process for following up on advance directives was inconsistent, especially after staff changes. The affected residents included individuals with varying cognitive abilities, including those with moderate cognitive impairment, those who were cognitively intact, and those who lacked capacity due to medical conditions such as anoxic brain injury or persistent vegetative state. Despite these differences, the facility did not consistently provide or document the provision of written information about advance directives, as required by policy and regulation.