Failure to Assist Resident in Formulating an Advance Directive
Penalty
Summary
The facility failed to ensure a resident and their representative received assistance to exercise the right to formulate an advance directive. Record review showed that one resident, admitted with multiple diagnoses including quadriplegia and depression, had a Physician Orders for Scope of Treatment (POST) form in the medical record but no documented advance directive. The record also lacked documentation that the facility had informed the resident or provided written information about the right to formulate an advance directive. During interview, the Administrator stated that the facility only had POST documents for this resident, confirming the absence of advance directive documentation or evidence of required information being provided. This deficient practice created the potential for harm or adverse outcomes if the resident’s wishes were not followed or documented regarding their advance care planning.
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