Failure to Inform Resident of Medical Appointments
Penalty
Summary
The facility failed to honor a resident's right to be informed and participate in their treatment decisions, as required by regulations. Specifically, the facility did not notify a resident of their medical appointments in advance, despite the resident's expressed desire to be informed. The resident, who was capable of understanding and communicating, had previously raised concerns about not being informed of appointments, and it was agreed that they would receive at least a week's notice. However, the resident was sent to a procedure without prior notification, as confirmed by interviews and clinical records. The deficiency was further evidenced by the lack of documentation in the resident's clinical record indicating that they were informed of appointments on two specific dates. The Director of Nursing confirmed the absence of such documentation and acknowledged that the resident's sister was notified instead, as she had requested to be informed. This oversight in communication and documentation led to the resident discovering an upcoming appointment through their patient portal rather than being informed by the facility staff.
Plan Of Correction
Preparation and submission of this Plan Of Correction (POC) is required by state and federal law. This Plan Of Correction (POC) does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. Facility could not go back and notify Resident #79 of a previous appointment. Facility clarified Resident #79 preference of notification at the time of the survey. To identify other residents with the potential to be affected, the Director of Nursing/designee will audit appointments for the previous month to see if notifications were made and documented. To prevent a future occurrence, the Director of Nursing/designee will educate nursing staff/transportation on the resident right to make informed choices and participate in his/her treatment. To monitor and maintain ongoing compliance, the Director of Nursing/designee will complete an audit of 10 appointments (if applicable) to ensure notifications are completed and documented weekly x4 and then monthly x2. Results of audits will be forwarded to facility's Quality Assurance and Process Improvement committee for review upon completion for review and recommendations.