Failure to Obtain Consent and Notify Representative for Resident Physical Contact
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed and able to participate in decisions regarding care and treatment, specifically related to physical contact and bed sharing between two residents with cognitive impairments. One resident, who had severe cognitive impairment due to dementia and Alzheimer's disease, was involved in repeated incidents where her roommate, who also had moderate cognitive impairment and behavioral disturbances, entered her bed and engaged in physical contact. Documentation in the electronic medical record (EMR) for the resident with severe impairment did not include evidence of consent for physical contact or notification to her representative regarding these events. Progress notes for the resident with behavioral disturbances detailed multiple occasions where she was found in bed with her roommate, standing over her, or following and touching her repetitively. Staff documented these behaviors and reported them to management, but there was no corresponding documentation in the roommate's EMR about these incidents or any notification to her representative. The facility's investigation concluded that the incidents were not sexually aggressive but rather companionship, and determined the occurrence to be unsubstantiated. Interviews with facility leadership confirmed there was no policy or consent form regarding physical contact or bed sharing between residents. The Director of Nursing and Corporate Representative stated that if a resident could not give consent, the representative should be contacted and documentation should be made, which did not occur in this case. The resident's representative reported she was not notified and would not have given consent for bed sharing, emphasizing that the decision should have been hers as Power of Attorney. Staff interviews corroborated that at least one incident involved the resident with behavioral disturbances lying on top of the other resident, and the administrator acknowledged that families should always be notified of such events.