Failure to Provide and Maintain Advance Directive Information and Documentation
Penalty
Summary
The facility failed to ensure that residents were provided with information about advance directives, did not obtain or maintain copies of advance directives in the medical record, and lacked a policy and procedure for implementing advance directives. For multiple residents, including those with cognitive impairment or communication barriers, the facility did not verify or provide appropriate advance directive information upon admission. In several cases, forms were completed at the hospital prior to transfer, but the facility did not follow up to ensure residents or their representatives received or understood the information, nor did they confirm the presence of advance directive documentation in the medical record. For one resident with no cognitive impairment, the hospital's documentation indicated a durable power of attorney (DPOA) for healthcare was provided, but the facility did not have a copy in either the electronic or physical chart. Another resident, who was rarely understood and had moderate cognitive impairment, was made to sign an advance directive acknowledgement form at the hospital, but facility staff confirmed the resident could not comprehend the information. Staff interviews revealed confusion about who was responsible for advance directives, with social workers and nurses stating they did not handle or verify this documentation, and in some cases, copies of DPOA were kept in private offices rather than in the medical record. Additional residents with significant communication or cognitive barriers, such as being non-verbal or legally blind, were documented as having received written materials about advance directives, but staff acknowledged these residents could not understand or read the information. In several instances, family members or representatives were identified as decision-makers, but the facility did not ensure they received the necessary information or that documentation was properly maintained and accessible. Staff interviews consistently indicated a lack of clarity and responsibility regarding the advance directive process within the facility.