Failure to Offer Cognitively Intact Resident Assistance With Advance Directive
Penalty
Summary
The facility failed to assist a cognitively intact resident in developing an advance directive for health care decisions as required. The resident, admitted with multiple diagnoses including right-sided paralysis following a heart attack, Parkinson's disease, cognitive communication deficit, depression, and anxiety, had a comprehensive MDS assessment documenting intact cognition. Record review of the resident's progress notes showed no documentation that the resident was offered the opportunity to create an advance directive. Additionally, multiple IDT care conferences held over several months did not document that the resident was provided information to formulate an advance directive. On review, the Administrator confirmed there was no documentation that the resident had been provided information to formulate an advance directive. This deficient practice created the potential for harm if residents' instructions for their healthcare were not followed in the event of a life-threatening outcome.
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