Failure to Provide Resident with Advance Directive Information
Penalty
Summary
The facility failed to provide a resident with information regarding the right to formulate an Advance Directive (AD), as required by policy and regulation. Upon review, the resident's AD Acknowledgement Form indicated that an AD had been executed, but the facility did not have a copy on file. The resident's admission record showed multiple diagnoses, including congestive heart failure, Type 2 diabetes, and vascular dementia, and assessments confirmed the resident had the capacity to make decisions. However, during an interdisciplinary team conference, it was noted that the resident was not aware of having an AD, and the POLST form indicated no AD was present. Interviews with the DON and Social Worker confirmed that the documentation was inconsistent and that there was no evidence the resident had been provided with information about ADs. Further review of facility policy revealed that written information about the right to accept or refuse treatment and to formulate an AD should have been provided to the resident or their representative upon admission. The DON acknowledged that the facility was not following its own policy, which required inquiry about existing ADs and provision of information in an understandable manner. The resident also stated she did not have an AD and did not recall receiving information about it from the facility. This series of actions and inactions led to the deficiency, as the facility did not ensure the resident was informed of her rights regarding advance directives.