Failure to Provide Information and Assistance for Advance Directive Formulation
Penalty
Summary
The facility failed to ensure a resident received information and assistance to formulate an advance directive as required by its Advance Directives and Advance Care Planning policy. The policy, reviewed on 9/26/25, stated that residents or their responsible parties are to receive materials upon admission regarding their rights to make decisions about medical care, including accepting or refusing treatment and forming advance directives. Resident #74 was admitted with multiple diagnoses including encephalopathy, diabetes, urinary retention, and a UTI, and a Social Services assessment documented that the resident did not have an advance directive. However, there was no documentation in the resident’s record that information was provided to help formulate an advance directive, and the Social Services Director confirmed that the resident did not have an advance directive and that the resident and/or representative should have been offered the opportunity to formulate one. This deficient practice created the potential for harm should residents' wishes regarding end of life or emergent care not be honored if they were incapacitated.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.