Failure to Provide Written Information on Advance Directives at Admission
Penalty
Summary
The facility failed to provide residents and their representatives with written information regarding advance directives and the right to accept or refuse medical or surgical treatment, as required by their own policy and federal regulations. Record review and interviews revealed that, for two residents, there was no evidence of an advance directive checklist, signed acknowledgment of receipt, or any documentation that written information about advance directives was provided at admission. The facility's admission packet did not include written materials about advance directives or the right to accept or refuse treatment, and there was no process in place to ensure residents or their representatives received or acknowledged this information. Interviews with the residents, their representatives, the Social Worker (who also served as the admission coordinator), and the Administrator confirmed that the facility's practice was to discuss only the Medical Order for Scope of Treatment (MOST) form, without providing any written literature about advance directives or the right to refuse care. Both residents and their representatives were unaware of what an advance directive was and did not recall receiving any information on the topic. The Social Worker and Administrator acknowledged that the facility did not include written information about advance directives in the admission process and were unaware of the requirement to do so.