Failure to Obtain Informed Consent and Complete POLST Forms
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding informed consent for medications and life-sustaining treatment orders. Resident 37, who was diagnosed with dementia, psychotic disorder, and schizophrenia, was prescribed Quetiapine and Divalproex Sodium without obtaining informed consent from the resident's representative or power of attorney. The facility's policy required the prescriber's signature on the informed consent within 24 hours of admission, but this was not completed, leaving the resident's representative unaware of the medication's risks, benefits, and alternatives. Additionally, the facility did not ensure that the Physician Orders for Life-Sustaining Treatment (POLST) forms for Residents 12, 69, and 14 were properly completed and signed by the responsible parties. Resident 12, with a moderately impaired cognitive status, had a POLST indicating DNR status, but it lacked the responsible party's signature, rendering it invalid. Similarly, Resident 69's POLST was missing the responsible party's signature, and Resident 14's POLST was prepared without obtaining the resident's signature. These omissions could lead to delays in care during emergencies, as the POLST forms serve as physician orders for medical professionals. The facility's policies and procedures for informed consent and POLST completion were not followed, resulting in incomplete documentation and potential delays in care. The Director of Nurses and other staff acknowledged the deficiencies, noting the importance of having valid POLST forms and informed consent to ensure residents and their representatives are aware of treatment options and preferences. The lack of proper documentation violated residents' rights to be informed and make decisions about their care, potentially affecting their quality of life and health outcomes.
Penalty
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A resident with severe cognitive impairment and BPH was ordered to have UA with C&S obtained each shift. When the resident was unable to void into a urinal, an LPN attempted in-and-out catheterization. According to a visitor and staff statements, the resident verbally and physically resisted, saying not to proceed and crossing his legs, but the LPN summoned two CNAs, who held the resident’s arms and legs while the catheter was inserted. Bright blood was observed in the urine, the procedure was stopped, and later the resident experienced pain with urination, hematuria, and blood clots, leading to transfer to the ER and return with an indwelling catheter and blood in the urine. Staff interviews and the facility’s investigation confirmed that the resident was restrained during the procedure despite refusal, and that this violated the resident’s right to refuse care and the facility’s abuse policy.
Facility staff administered Ativan by injection to a resident with no cognitive impairment after the resident refused the oral form, without providing an opportunity to consent to or refuse the injection. Staff interviews and record review confirmed that required consent procedures were not followed, despite facility policy mandating resident rights to refuse medication.
Facility staff did not inform a resident or their representative about the risks, benefits, or alternative treatments for lorazepam, an anti-anxiety medication, despite a physician's order for its use. Documentation and staff interviews confirmed that this required information was not provided, contrary to facility policy.
Facility staff did not inform a cognitively intact resident about new orders for Percocet and Xanax, nor did they provide information on the risks, benefits, or alternatives before administering these medications. Despite care plan requirements and facility policy mandating resident education and involvement in care decisions, there was no evidence that the resident was notified or educated prior to receiving the medications.
A resident with multiple diagnoses, including dementia and diabetes, was not given the opportunity to participate in their care planning, despite being assessed as cognitively intact. Staff interviews confirmed that documentation of the resident's involvement was missing, and no evidence was found in the clinical record to show the resident was invited to participate in treatment planning.
Facility staff did not provide a resident with education or the opportunity to refuse psychoactive medications, specifically Risperidone and Sertraline, as required by facility policy. Documentation was lacking to show that the resident or their representative was informed about the risks, benefits, or alternatives to these medications before administration.
Resident forcibly catheterized for urine specimen after refusing procedure
Penalty
Summary
Facility staff failed to uphold a resident’s right to refuse care and treatment when attempting to obtain a urine specimen from Resident #42. The resident had diagnoses including benign prostatic hyperplasia and was documented on the admission MDS with a BIMS score of 4/15, indicating severely impaired cognition for making daily decisions, and was coded as always incontinent. A physician’s order directed that a urinalysis with culture and sensitivity be obtained every shift for three days. On the evening in question, the LPN attempted to collect a urine sample via in-and-out catheterization after the resident was unable to void into a urinal. According to the facility’s synopsis and staff statements, when the LPN entered the room to insert the catheter, the resident verbally and physically resisted the procedure. A friend visiting the resident reported that the resident said “Don’t do that” and crossed his legs, and later grabbed his penis to stop the nurse. The LPN then called for assistance from two CNAs. The friend was asked to step into the hallway, where she heard the resident yelling but could not make out his words. CNA #14 reported that he and CNA #15 held the resident’s legs and arms while the LPN catheterized him, and the facility’s investigation concluded that the CNAs restrained the resident’s arms and legs during the catheter insertion. The LPN confirmed that the resident was restrained during the procedure and stated that restraining residents during care was common practice, and she expressed surprise when informed that residents have the right to refuse care and cannot be restrained against their will. During the catheterization, bright blood was noted in the urine sample, and the LPN stopped the procedure and removed the catheter. A health status note documented that the resident appeared anxious but stable, with no signs of shock or distress at that time, and the on-call NP was notified and directed staff to monitor the resident. Later that night and early the following morning, staff documented that the resident had discomfort and pain with urination, hematuria, and blood clots noted in the brief, and the NP ordered transfer to the emergency room. The resident was hospitalized due to hematuria and returned with an indwelling urinary catheter and blood in the urine. The facility’s grievance report and internal investigation documented that the urine catheter was placed for a specimen after the resident’s refusal, that staff held the resident down during the procedure, and that the incident was substantiated as abuse and a violation of the resident’s rights. Interviews with other staff further described the expected procedure for obtaining a urine specimen and the requirement to stop if a resident refuses, asks to stop, or shows distress, and to notify the physician if urine cannot be obtained. The Senior Director of Nursing Services, another LPN, and a CNA all acknowledged that residents have the right to refuse care, treatments, or procedures and agreed that the resident’s rights were violated in this incident. The facility’s abuse, neglect, and exploitation policy states that each resident has the right to be free from abuse and that team members must not engage in or permit abuse. The events described show that, despite the resident’s severe cognitive impairment, staff proceeded with catheterization by physically restraining the resident after he verbally and physically resisted, resulting in bleeding, pain with urination, hematuria, and hospitalization.
Failure to Obtain Consent for Psychoactive Medication Administration
Penalty
Summary
Facility staff failed to obtain consent from a resident prior to administering a psychoactive medication, Ativan, on 3/1/25. The resident was assessed as having no cognitive impairment, scoring 15 out of 15 on the BIMS, and was identified as her own responsible party. Clinical records showed no change in cognitive status and documented that the resident was offered Ativan orally, which she refused. Despite this, staff proceeded to administer Ativan by intramuscular injection without evidence that the resident was given the opportunity to consent to or refuse the injection. Staff interviews confirmed that facility policy requires resident or responsible party notification and consent prior to medication administration, and that residents have the right to refuse any medication or treatment. The staff acknowledged that, although non-pharmacological interventions were attempted and the resident refused the oral medication, there was no documentation or evidence that the resident was given the opportunity to refuse the Ativan injection. Facility policy also states that all patients have the right to refuse medications, and that nurses are responsible for providing education regarding risks, but no such documentation was found in this case.
Failure to Inform Resident of Medication Risks, Benefits, and Alternatives
Penalty
Summary
Facility staff failed to inform a resident or the resident's representative about the risks, benefits, and alternative treatments associated with the use of lorazepam, an anti-anxiety medication. A physician's order was present for lorazepam to be administered as needed for anxiety, sleeplessness, seizure activity, or shortness of breath, but there was no documentation in the clinical record indicating that the required information was provided to the resident or their representative. Staff interviews confirmed that such information should be communicated, including details about targeted behaviors, side effects, and alternative treatments, but this was not done in this case. The facility's own policy states that residents have the right to be fully informed in advance about care and treatment, but this was not followed for the resident in question.
Failure to Inform Resident of New Medication Orders and Associated Risks
Penalty
Summary
Facility staff failed to notify a cognitively intact resident of new physician orders for the administration of Percocet and Xanax, including the associated risks, benefits, and alternatives. The resident, who had diagnoses including cancer of the larynx and anxiety, was admitted with a PEG tube and was capable of making daily decisions as indicated by a high BIMS score. Despite physician orders for these controlled medications and documented administration on multiple occasions, there was no evidence that the resident was informed in advance about the medications or their potential effects. The resident's care plan included an intervention to educate the resident and their family or caregivers about the risks, benefits, and side effects of medications being given. However, interviews with facility staff confirmed that no documentation or evidence existed to show that this education or notification occurred prior to the administration of Percocet and Xanax. The facility's policy requires residents to be informed and participate in care planning and treatment, but this was not followed in this instance.
Resident Not Afforded Opportunity to Participate in Care Planning
Penalty
Summary
Facility staff failed to ensure that a resident was given the opportunity to participate in their ongoing treatment and care planning. Record review showed no evidence that the resident, who had diagnoses including dementia with behavioral disturbance, diabetes, depression, anxiety, and chronic kidney disease, was invited to participate in care planning discussions. The most recent MDS assessment indicated the resident was cognitively intact, with a score of 15 out of 15. During interviews, both the social worker and the director of social services were unable to provide documentation showing the resident's involvement in care planning, despite facility practice to invite residents to such meetings on admission, quarterly, annually, and upon significant change in status. The resident was not available for interview during the survey as they were on leave with family. No additional information or documentation was provided by staff prior to the exit conference.
Failure to Provide Education and Refusal Opportunity for Psychoactive Medications
Penalty
Summary
Facility staff failed to provide required education and the opportunity to refuse psychoactive medications for one resident. Clinical record review showed that the resident was prescribed Risperidone 0.5 mg daily and Sertraline 50 mg daily, and these medications were administered as ordered. However, there was no documentation in the medical record indicating that the resident or their representative was informed about the risks and benefits of these medications, nor was there evidence that the resident was given the option to refuse them. Interviews with facility staff, including the director of nursing, confirmed that the facility's policy requires obtaining consent and providing education regarding psychotropic medications, which carry specialized risks for side effects. The facility's own policy also states that residents have the right to accept or decline such medications after being informed of the risks, benefits, and alternatives. Despite these requirements, no documentation or evidence of such education or opportunity for refusal was found for the resident in question.
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