Resident's Right to Refuse Urine Toxicology Test Not Honored
Penalty
Summary
A cognitively intact resident with quadriplegia, chronic pain syndrome, and a history of stimulant use disorder was admitted to the facility and had a physician's order for a urine toxicology screen. According to nursing notes and staff interviews, the resident refused the urine toxicology test, and this refusal was documented in the electronic health record. Despite the resident's refusal, staff proceeded to collect a urine sample and sent it to the laboratory for toxicology screening, which later returned positive for amphetamines. Interviews with nursing staff confirmed that the resident's right to refuse the test was not honored, even though facility policy requires resident rights to be protected and promoted. The resident was alert, oriented, and able to communicate his wishes, explicitly stating that he had refused the test. The facility's actions resulted in a violation of the resident's right to make medical decisions regarding their care and treatment.