Failure to Follow Policy for Decision-Making Capacity Assessment and Documentation
Penalty
Summary
Facility staff failed to follow their own policy regarding decision-making capacity assessments for a resident admitted with multiple complex diagnoses, including a right pubis fracture, repeated falls, severe protein-calorie malnutrition, dysphagia, and abnormal weight loss. Concerns were raised by the resident's daughter about the resident's cognition, prompting a discussion with the Social Work Director about the need for a competency evaluation and the possible activation of the resident's Durable Power of Attorney (DPOA). However, this discussion was not documented in the progress notes, and the psychiatric consult to determine capacity was not completed until several weeks later. The evaluation for decision-making capacity was ultimately performed by a contracted physician, who determined the resident lacked capacity due to delirium and encephalopathy. The required facility form, "Physician Statement of Capacity for Medical Treatment and Decisions," was signed by this physician as the second examiner, although they were actually the first to evaluate the resident. The attending physician signed the form the following day, despite the resident having already been transferred to the hospital and not being present in the facility. There was no documentation in the medical record that the attending physician or any other attending clinicians had evaluated the resident for capacity. Additionally, the original capacity form was not found in the resident's medical record, and staff could not provide it when requested. The facility's policy required that two physicians determine incapacity, with thorough examinations and proper documentation uploaded to the resident's chart. These steps were not followed, as only one physician evaluated the resident, and the documentation process was incomplete and inconsistent with facility policy.
Plan Of Correction
F 745 Provision of Medically Related Social Services It is the practice of the facility to ensure that all residents receive medically related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to follow the policy on capacity decision making for 1 of 4 residents. Element 1 R402 no longer resides at the facility. Element 2 Residents that require a capacity evaluation have the potential to be affected by the cited practice. An audit was completed for residents that have had a capacity evaluation completed to ensure the policy was followed and all appropriate paperwork and documentation is in place. Any deficiencies noted in the audit were immediately corrected. Element 3 The Interdisciplinary Team reviewed the Decision-Making Capacity Policy and deemed it appropriate. All social service staff and the attending physicians have been educated on the policy and procedure with emphasis on ensuring capacity evaluations are being completed timely and with appropriate documentation. Element 4 The Social Service Director, or designee, will complete random audits on residents with a request for a capacity evaluation weekly x 4 weeks then monthly x3. Element 5 The administrator is responsible for compliance with a compliance date of May 6th, 2025.