Failure to Provide Opportunity for Advance Directive Formulation and Review
Penalty
Summary
The facility failed to provide two residents with the opportunity to formulate an advance directive or to conduct periodic reviews of their advance directive status, as required by facility policy and state regulations. Review of the clinical records for both residents, who were cognitively intact with BIMS scores of 15, showed no documentation that they had been given written information about their right to accept or refuse medical treatment or to create an advance directive upon admission. Additionally, there was no evidence in their records that periodic reviews of advance directive instructions had occurred. Both residents had significant medical histories, including diagnoses such as adult failure to thrive, anxiety, depression, diabetes mellitus, osteomyelitis, and toe amputation. Despite these conditions and their cognitive ability to participate in care planning, the facility did not document any discussion or provision of information regarding advance directives. The deficiency was confirmed by the Nursing Home Administrator during an interview, acknowledging the lack of compliance for these two residents.