§483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
§483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate.
§483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives).
(i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.
(ii) This includes a written description of the facility's policies to implement advance directives and applicable State law.
(iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met.
(iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State law.
(v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.
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Observations:
Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide the opportunity to formulate an advance directive (written instructions such as a living will or durable power of attorney for health care for when the individual is incapacitated) for two of five residents reviewed (Resident R38,R57).
Findings Include:
A review of the facility policy "Advanced Directives" on 1/1/2024, indicated the facility will comply with the requirements related to maintaining written policies and procedures regarding advance directives, including provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and formulate an advance directive.
A review of the medical record indicated Resident R38 was admitted to the facility on 6/1/23, with diagnoses that included diabetes(high blood sugar), high blood pressure, congestive heart failure(chronic condition in which the heart doesn't pump blood as well as it should), and morbid (severe) obesity.
A review of the clinical record failed to reveal an advance directive or documentation that Resident R38 was given the opportunity to formulate an Advanced Directive.
A review of the clinical record indicated Resident R57 was admitted to the facility on 6/16/21, with diagnoses that included morbid (severe) obesity, hypertensive heart disease with heart failure (uncontrolled high blood pressure that lead to the heart not being able to pump correctly), chronic obstructive pulmonary disease (COPD-a combination of lung diseases that block airflow and make it difficult to breathe), and wound to right lower leg.
A review of the clinical record failed to reveal an advance directive or documentation that Resident R21 was given the opportunity to formulate an Advanced Directive.
During an interview on 6/13/2024, at 10:32 p.m. the DON and Social Worker Employee E17 confirmed that the clinical record did not include documentation that Resident R38 and R57 were afforded the opportunity to formulate Advance Directives.
28 PA. Code 201.29(b)(d)(j) Resident rights.
| | Plan of Correction - To be completed: 07/01/2024
Preparation and submission of this POC is required by state and federal law. This POC does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
Social services met with R38 and R57 to educate on and offer assistance with completing an advanced directive.
Social services or designee will review current residents to ensure all have advanced directives in place or documented declinations.
To prevent this from happening again the NHA or designee will re-educate social services on screening for advanced directives on admission and providing assistance as needed.
To monitor and maintain on going compliance the NHA/designee will audit new/re-admission records weekly for 4 weeks then monthly for two months to ensure advance directives are in place or a documented declination is in the EHR.
Results will be taken to the QAPI for review and revision as needed.
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