Failure to Document Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide documentation that residents or their representatives were given the opportunity to formulate an advance directive, as required by federal regulations. Specifically, for two of four residents reviewed, there was no evidence in the clinical records that the residents were informed about or offered the chance to create an advance directive, such as a living will or durable power of attorney for health care. The facility's policy states that upon admission, staff should determine if a resident has an advance directive and, if not, offer information and the opportunity to formulate one, but this was not documented for the affected residents. One resident had diagnoses including depression, neurogenic bladder, and quadriplegia, while another had chronic obstructive pulmonary disease (COPD), muscle weakness, and cancer. Despite these significant medical conditions, their records did not contain an advance directive or documentation of being given the opportunity to create one. The facility's social worker confirmed during an interview that this documentation was missing for these residents.
Plan Of Correction
Resident R3 and Resident R44 were both given the opportunity for Advanced Directives, and the Social Worker documented they were provided. The Social Worker will look back for the past 30 days and review documentation of advanced directives with new Admissions. The Administrator educated the Social Worker on the need to document that advanced directives were given to new admissions. The Social Worker or designee will document new admission advanced directives weekly times 3 and monthly times 2. Results will be turned into the monthly Quality Assurance meeting.