Failure to Consult IDT or Bioethics Committee for Vaccination Consent in Incapacitated Resident
Penalty
Summary
The facility failed to ensure that staff consulted with a physician, the Interdisciplinary Team (IDT), or the facility 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 indicated by both the history and physical and a BIMS score of 10. Despite this, the resident's vaccination consent forms for pneumonia, influenza, and COVID-19 were signed as refusals by the resident, without appropriate consultation with the physician, IDT, or Bioethics Committee. The Director of Nursing confirmed that the resident should not have signed the informed consent due to lack of capacity and that the required consultations did not occur. Facility policies required obtaining treatment consent for non-routine care and outlined the use of the Bioethics Committee to support residents' healthcare decision-making, but these procedures were not followed in this case.