Failure to Assist Residents With Formulating Healthcare Advance Directives
Penalty
Summary
The facility failed to ensure that residents and their representatives received assistance to exercise their right to formulate an advance directive, as required by the facility’s Advance Directives policy. That policy, last reviewed on 12/1/25, stated that all residents or their responsible parties receive materials concerning their rights under applicable laws to make decisions regarding their medical care, including the formation of advance directives upon admission. Record review showed that four residents admitted with multiple medical diagnoses did not have an advance directive for healthcare in their medical records, nor documentation that they were provided information on their right to formulate one. One resident with polyneuropathy and diabetes, another with a left femur fracture and dementia, another with hemiplegia and hemiparesis following a stroke, and another with cancer, hypertension, and lumbar spinal stenosis all lacked healthcare advance directives or documentation of being informed of their right to create one. The Social Services Director and the DON confirmed that these residents only had financial or general powers of attorney on file and did not have a Durable Power of Attorney for Healthcare or other healthcare advance directive, and that they were not offered the opportunity to formulate one.
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