Failure to Assist with or Document Advance Directives for Two Residents
Penalty
Summary
The facility failed to assist with or obtain Advance Directives (AD) for two residents, resulting in a deficiency related to honoring residents' rights to specify their healthcare preferences. For one resident with a history of COPD and dementia, the Social Service Director acknowledged that while a Physician Orders for Life Sustaining Treatment (POLST) was present in the clinical record, there was no AD on file. The Admissions Coordinator was unable to find documentation that an AD was requested, refused, discontinued, or offered, and only a consent to treat form was signed by the resident's responsible party. The Director of Nursing confirmed that it was expected for ADs to be part of the clinical chart and emphasized the importance of knowing who would be responsible for healthcare decisions. For another resident admitted with a corneal ulcer and blindness in one eye, the Director of Nursing and Admissions Director both confirmed that there was no documentation of an AD being offered, accepted, or declined. The resident reported that the admission agreement was read quickly and that he was not offered assistance with creating an AD, despite the facility's policy stating that staff would offer such assistance and document the resident's decision. The lack of documentation and failure to offer or assist with ADs for these residents constituted the identified deficiency.