Failure to Consult IDT or Bioethics Committee for Vaccination Consent in Cognitively Impaired Resident
Penalty
Summary
Staff failed to consult with a physician, the Interdisciplinary Team (IDT), or the facility's Bioethics Committee regarding vaccination decisions for a resident who lacked both decision-making capacity and a representative. The resident, who had diagnoses including adult failure to thrive, anemia, and cholelithiasis, was assessed as moderately cognitively impaired and dependent on staff for daily activities. Documentation showed that the resident did not have the capacity to understand or make medical decisions, as confirmed by both the History and Physical and the BIMS score. Despite this, vaccination consent forms for pneumonia, influenza, and COVID-19 were signed as refusals by the resident, without appropriate consultation or surrogate decision-making. The Director of Nursing acknowledged that the resident should not have signed the informed consent forms and that the required process of involving the physician, IDT, or Bioethics Committee was not followed. Facility policy required treatment consent for non-routine care and outlined the use of the Bioethics Committee to support residents' healthcare decision-making rights, but these procedures were not implemented in this case.