Failure to Provide and Document Assistance With Advance Directives for Two Residents
Penalty
Summary
The facility failed to ensure residents and their representatives received assistance to exercise their right to formulate an advance directive, as required by facility policy. The Nursing Administration – Advance Directive Documentation policy (revised December 2019) required that, at admission, residents be provided written information regarding advance directives and that the medical record document whether the resident had executed such a document. For one resident with diagnoses including acute posthemorrhagic anemia and COPD, the social services assessment documented that the resident had an advance directive, but the medical record contained only a Durable Power of Attorney for financial matters, not for medical decisions. The record lacked any advance directive and lacked documentation that information about advance directives was provided or discussed with the resident or her representative. The LSW confirmed that this resident did not have an advance directive or documentation that she was offered assistance to formulate one and that she should have. Another resident, admitted with diagnoses including acute respiratory failure with hypercapnia, schizoaffective disorder, and AFib, also had no documentation of an advance directive in the medical record. Review of this resident’s record showed no evidence that an advance directive existed or that the resident or his guardian had been offered assistance to formulate one. The DON confirmed there was no advance directive in the record and that neither the resident nor his guardian had been offered the opportunity to formulate an advance directive. The surveyors determined that, for 2 of 17 residents reviewed for advance directives, the facility did not follow its policy or regulatory requirements to provide information and assistance regarding advance directives and to document this in the medical record.
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