Failure to Offer and Document Opportunity to Formulate Advance Directive
Penalty
Summary
The facility failed to ensure a resident was informed of and given the opportunity to formulate an advance directive as required by its own policy and regulatory standards. The facility’s written policy on advance directives, revised in September 2022, states that prior to or upon admission, the Social Services Director or designee must inquire about any existing written advance directives, provide written information on the right to accept or refuse medical or surgical treatment, and inform the resident or representative of the right to formulate an advance directive. The policy also requires that this information be provided in an easily understood manner and include a description of the facility’s policies and applicable state law. For one resident reviewed, identified as Resident 39, the clinical record did not contain any documentation that staff had reviewed the resident’s right to formulate an advance directive or offered the opportunity to do so. Resident 39 had physician orders reflecting diagnoses including hypertension and chronic kidney disease, and a recent BIMS assessment showed a score of 15/15, indicating intact cognition. During an interview, the Social Worker (Employee 3) confirmed there was no documentation that the resident had been offered the opportunity to formulate an advance directive. This lack of documentation and action constituted the identified deficiency.
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