§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 the 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 nine of the sixteen residents reviewed (Resident R14, R18, R48, R84, R86, R96, R98, R99, R108).
Findings Include:
A review of the facility policy "Advanced Directives" reviewed 3/1/2023 and 1/31/2024, 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 R14 was admitted to the facility on 9/26/2023, with diagnoses that included Parkinson ' s disease (affects movement of muscles often seen with tremors, shaking), diabetes, and depression.
A review of the clinical record failed to reveal an advance directive or documentation that Resident R14 was given the opportunity to formulate an Advanced Directive.
A review of the clinical record indicated Resident R18 was re-admitted to the facility on 1/6/2020, with diagnoses that include diabetes, high blood pressure, and paraplegia (no movement of lower body or legs).
A review of the clinical record failed to reveal an advance directive or documentation that Resident R18 was given the opportunity to formulate an Advanced Directive.
A review of the clinical record indicated Resident R43 was admitted to the facility on 4/22/2022, with diagnoses that include high blood pressure, gastro-esophageal reflux disease (GERD-severe indigestion), gastro-intestinal bleed (bleeding from either the stomach or the intestines).
A review of the clinical record failed to reveal an advance directive or documentation that Resident R43 was given the opportunity to formulate an Advanced Directive.
A review of the clinical record indicated Resident R84 was admitted to the facility on 12/22/2021, with diagnoses that include diabetes, morbid obesity (severely overweight) and foot drop of both feet (unable to lift the foot into a normal position to allow you to walk).
A review of the clinical record failed to reveal an advance directive or documentation that Resident R84 was given the opportunity to formulate an Advanced Directive.
A review of the clinical record indicated Resident R87 was re- admitted to the facility on 3/8/2024, with diagnoses that include diabetes, high blood pressure, and GERD.
A review of the clinical record failed to reveal an advance directive or documentation that Resident R87 was given the opportunity to formulate an Advanced Directive.
A review of the clinical record indicated Resident R96 was re-admitted to the facility on 9/26/2023, with diagnoses that include diabetes, high blood pressure, left leg below knee amputation.
A review of the clinical record failed to reveal an advance directive or documentation that Resident R96 was given the opportunity to formulate an Advanced Directive.
A review of the clinical record indicated Resident R98 was admitted to the facility on 6/22/2023, with diagnoses that include high blood pressure, chronic pain, and cancer.
A review of the clinical record failed to reveal an advance directive or documentation that Resident R98 was given the opportunity to formulate an Advanced Directive.
A review of the clinical record indicated Resident R99 was admitted to the facility on 11/15/2023, with diagnoses that include chronic obstructive pulmonary disease (COPD-tightening of the airways making it difficult to breath), stroke (an interruption of the blood flow within your brain that causes the death of brain cells), and depression.
A review of the clinical record failed to reveal an advance directive or documentation that Resident R99 was given the opportunity to formulate an Advanced Directive.
A review of the clinical record indicated Resident R108 was admitted to the facility on 2/20/2024, with diagnoses that include dysphagia (difficulty swallowing), difficulty walking and muscle weakness.
A review of the clinical record failed to reveal an advance directive or documentation that Resident R108 was given the opportunity to formulate an Advance Directive.
During an interview on 3/13/2024, at 2:28 p.m. the Social Worker Employee E1 and Medical Records Employee E2 stated she confused the POLST with Advance Directives, confirming Residents (Resident R14, R18, R43, R84, R87, R96, R98, R99, R108), were not afforded the opportunity to formulate Advance Directives upon admissions and periodically during their stay in the facility.
28 Pa. Code: 201.29(b)(d)(j) Resident rights.
| | Plan of Correction - To be completed: 04/02/2024
Social Service Director, Social Service Coordinator, Business Office Manager, Admission Director, and all Registered Nurses were immediately educated by NHA on the completion of the Social History Assessment and Screening for existence of Advanced Directives for all residents on admission.
Social Service Director/designee immediately offered information on the process of formulating Advanced Directives to the 9 subject residents.
Social Service Director/designee immediately conducted a facility wide audit to ascertain resident who have or do not Advanced Directives. Using a screening tool will identify and offer information to those who wish to have one on how to formulate an advanced directive. Screening tool will be kept in the MR.
Social Service will audit new admissions for completion of the Advanced Directive screening tool weekly x 4 then monthly x 2.
Results will be discussed in QAPI.
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