Failure to Formulate or Offer Advance Directive Upon Admission
Penalty
Summary
The facility failed to formulate or offer to formulate an advance directive for one resident upon admission, despite the resident having multiple significant medical diagnoses, including cerebral infarction due to embolism, acute respiratory failure with hypoxia, acute on chronic diastolic heart failure, type 2 diabetes mellitus, anxiety disorder, chronic obstructive pulmonary disease, and unspecified intellectual disabilities. The resident's face sheet and physician order summary did not include a code status or advance directive, and the care plan lacked a focused area addressing the resident's choices regarding advance directives. The POLST (Physician Order for Life-Sustaining Treatment) form was not completed at the time of admission, and there was confusion among staff regarding who was responsible for ensuring its completion. Interviews with facility staff revealed a lack of clarity and communication about the process for obtaining and documenting code status and advance directives. The administrator was unaware of the facility's policy on when POLST forms should be completed, and the social services director indicated a preference for residents to arrive with a completed POLST from the hospital. The social services director also noted that the resident was difficult to assess due to behaviors and a low BIMS score, and had not reviewed all hospital paperwork or ensured the POLST was completed. The nurse practitioner confirmed that no discussion had occurred with the resident's family regarding code status, and that in the absence of a POLST, the resident was automatically considered a full code. Facility policy required that written information about advance directives be provided to residents prior to or upon admission, and that staff inquire about the existence of any written advance directives. However, these procedures were not followed for this resident, resulting in a lack of documented code status or advance directive for 12 days after admission. Multiple staff members expressed uncertainty about their roles and responsibilities in this process, contributing to the deficiency.