Failure to Notify Guardian of Resident's Refusal of Procedure
Penalty
Summary
The facility failed to notify a resident's legal guardian of the resident's refusal to undergo a planned abdominal CAT scan. The resident, who had diagnoses including unspecified dementia, depression, and gastrostomy status, was accompanied by a CNA to the imaging appointment but repeatedly refused to transfer onto the exam table, resulting in the cancellation of the test. The resident's medical record indicated a memory problem, and court documents confirmed that the resident's daughter was the current legal guardian, with a Guardian Ad Litem appointed to independently assess the resident's best interests. Despite the facility's policy requiring prompt notification of the resident's representative regarding changes in medical or mental condition, the legal guardian was not informed of the resident's refusal of the procedure. Interviews with facility leadership confirmed that the guardian was not notified, and a representative from the probate court reiterated that the daughter remained the valid guardian at the time of the incident.