Failure to Provide Information and Maintain Documentation of Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to provide required information about advance directives and to obtain and maintain documentation of residents’ advance directives in the medical record. For one resident admitted on an unspecified date, the admission MDS showed severe cognitive impairment, and the care plan dated 1/26/26 listed the resident as full code. However, there was no documentation in the record that the resident’s representative had been provided written information about the right to refuse medical or surgical treatment or to formulate an advance directive. The resident’s representative reported that no facility representative had discussed any information regarding an advance directive, and the social worker confirmed she had been on leave at the time of admission and indicated it would have been the previous social worker’s responsibility to address advance directives. For a second resident, multiple care plan notes and psychosocial discharge planning assessments documented that the responsible party reported the resident had an advance directive and confirmed full code status, and that guardianship paperwork would be brought in. Despite this, there was no documentation that the social worker requested or obtained a copy of the advance directive beyond the initial conversation, and subsequent care plan notes did not reflect follow-up requests. The psychosocial assessments repeatedly recorded that the resident was assessed to have an advance directive per the responsible party, but the medical record contained no copy of the advance directive. Interviews with social work staff and the administrator confirmed that the facility’s practice was to discuss advance directives upon admission, determine whether an advance directive existed, and request a copy for the medical record, with follow-up at subsequent care conferences if the document was not initially provided. In the case of the second resident, the current social worker acknowledged that the responsible party had not brought in the advance directive and that she did not follow up, and the prior social worker stated she believed she had not followed up due to difficulty reaching the responsible party. The administrator stated she expected social workers to discuss advance directives within three days of admission and to obtain and maintain copies in the medical record, which did not occur for these two residents.
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.