Failure to Offer and Assist with Advance Directives
Penalty
Summary
The facility failed to follow its policy and procedure regarding advance directives (AD) for six of eight sampled residents. For each of these residents, documentation such as the face sheet and POLST forms indicated either that no advance directive was present or that it was not available. Further review of the clinical records for these residents showed no evidence that the facility discussed, offered, or assisted them in executing an advance directive, as required by facility policy. During interviews, both the Social Service Director (SSD) and a Registered Nurse (RN) confirmed that there was no documentation of AD discussions or assistance for these residents. The SSD acknowledged that she had not discussed, offered, or assisted the residents with advance directives, and the RN confirmed that the SSD was responsible for this process but had not completed it. The facility's policy states that staff must offer assistance in establishing advance directives if a resident has not already done so, but this was not carried out for the identified residents.