Failure to Inform Resident of Treatment Rights and Advance Directive Options
Penalty
Summary
The facility failed to inform and provide written information to a cognitively intact resident regarding the right to accept or refuse medical or surgical treatment and to formulate an advance directive. The resident was admitted on a specified date, and the nursing admission assessment documented that the resident was cognitively intact. However, there was no documentation in the medical record that the resident had been informed of the right to accept or decline medical or surgical treatment prior to making an advance directive decision, nor was there any advance directive or code status documented. During interview, the resident reported not receiving any paperwork or education on advance directives and stated a desire to be resuscitated if the heart stopped. Staff interviews confirmed the lack of required information and documentation. The Social Worker acknowledged that the facility had not informed the resident of the right to accept or decline treatment or to formulate an advance directive and explained that her practice was to provide advance directive information only if residents requested it. A nurse verified there was no code status order in the physician orders or in the code status book and was unsure why an order was missing. The DON stated she expected the admitting nurse to obtain code status and a physician order, and the Social Worker to provide advance directive education, while the Administrator stated an expectation that staff explain advance directive choices and that a code status order be in place, but was unaware that written documentation needed to be provided or who was responsible for providing it.
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