Failure to Obtain and Document Complete Informed Consents for Care and Treatment
Penalty
Summary
The facility failed to ensure that accurate and complete informed consents were obtained for several residents, as required by its own policies and procedures. For multiple residents who lacked capacity to make their own medical decisions and had no legal surrogate, the required process involving the facility's Interdisciplinary Team (IDT) and inclusion of an unaffiliated resident representative, such as the Ombudsman, was not followed. In several cases, consent forms were either incomplete, missing required signatures, or improperly filled out, with sections for the resident's legal representative left blank or simply marked as 'IDT' without a signature or date. Interviews with the Administrator and DON confirmed that the Ombudsman had not participated in the Bioethics Committee/IDT meetings for over a year, contrary to facility policy, and that the Administrator should have signed as the responsible party on behalf of the IDT. For residents who were unable to make medical decisions, such as those prescribed psychotropic and antidepressant medications, the documentation of informed consent was inconsistent and incomplete. Forms for these residents often lacked the name and signature of the person who obtained consent, the date, and the required witness information. In some cases, the forms indicated that consent was obtained from the resident, despite documentation showing the resident lacked decision-making capacity. Additionally, for one resident, the consent for advanced wound care services was obtained from the resident, even though the medical record indicated the resident was unable to provide consent. Other deficiencies included missing or incomplete information on consent forms for residents who could make their needs known but not medical decisions. For example, forms were missing the date and signature of the person who placed a consent call, the date and signature of the eligible provider or clinician, the date and name/signature of a witness, and the date and signature of the resident or their power of attorney. In some cases, instructions for distributing copies of the consent forms were not followed, and the required information was not completed. Interviews with nursing staff and the DON confirmed these findings and acknowledged that the informed consents should have been properly signed and dated according to policy.