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F0551
D

Failure to Obtain Proper Medical Consents from Legal Health Care Representative

Muncie, Indiana Survey Completed on 05-02-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the designated legal health care representative signed medical consent forms for a resident who had been declared legally incompetent. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and cirrhosis of the liver, was admitted with a court order appointing a non-family member as the legal health care representative with full authority to make health care decisions. Despite this, the resident's daughter, who was not the legal health care representative, signed multiple consent forms, including mental health consent, psychotropic medication informed consent, and a POST form, after informing staff she was not the authorized representative. Facility staff were aware that the legal health care representative was unavailable due to being on vacation and made attempts to contact him, including leaving a voicemail and speaking with his appointed contact person. However, the necessary consent forms were not sent to the legal health care representative by email, and the daughter was asked to sign the forms in the interim. The facility did not obtain the required signatures from the court-appointed representative prior to executing medical consents.

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