Failure to Notify Resident's Legal Guardian Prior to Lung Surgery
Penalty
Summary
The facility failed to ensure that a resident's legal guardian, the Public Administrator (PA), was informed in advance of a significant medical treatment—lung surgery to remove the right upper lobe for cancer. According to the facility's policy, the nurse supervisor or charge nurse is required to notify the resident's family or representative within 24 hours of a significant change in condition or the need for hospital transfer, except in emergencies. Documentation and interviews revealed that the PA was not notified prior to the surgery, and there was no evidence in the resident's progress notes of communication with the PA regarding the surgery. The resident in question had moderate cognitive impairment and diagnoses including COPD, lung cancer, bipolar disorder, and a personality disorder. The care plan specified that the PA should be actively involved in care decisions, including being invited to meetings and contacted about concerns. The last documented contact with the PA's office regarding the resident's lung cancer was for consent to a bronchoscope procedure, with no further communication about the subsequent surgery. The PA's office only became aware of the surgery after the resident personally called them following the procedure. Interviews with facility staff, including the ADON, LPNs, and CMT, confirmed that the responsibility for notifying the PA lay with the charge nurse or DON, but none could confirm that notification occurred. Staff cited changes in administration and lack of documentation as contributing factors. The administrator and DON acknowledged that approval from the PA should have been obtained prior to treatment, and that progress notes should reflect such communication, but were unable to verify that this was done.