Failure to Ensure Informed Consent for Resident with Fluctuating Capacity
Penalty
Summary
Licensed nursing staff failed to follow facility policy and procedure regarding the interdisciplinary (IDT)/Bioethics review process for a resident with fluctuating capacity to understand and make decisions. The resident, who was admitted with diagnoses including metabolic encephalopathy, major depressive disorder, memory deficit, and cerebrovascular disease, exhibited moderate cognitive impairment and was dependent on staff for activities of daily living. Documentation and interviews confirmed that the resident experienced periods of confusion and disorientation, with staff noting difficulty in communication and episodes of hallucination. Despite the resident's fluctuating decision-making capacity, the facility did not ensure that an IDT/Bioethics review was conducted as required by their policy. The social worker was not involved in obtaining consent, and the facility administrator could not demonstrate how consent was obtained during periods when the resident had capacity. The facility also failed to document efforts to identify or involve a legal decision-maker or resident representative, as outlined in their policy, thereby violating the resident's right to make informed decisions about care and the use of psychoactive medications.