Failure to Obtain Informed Consent from Responsible Party for Resident Lacking Capacity
Penalty
Summary
The facility failed to obtain informed consent from a resident's responsible party for the administration of vaccines to a resident with severe cognitive impairment. The resident, who had diagnoses including metabolic encephalopathy and dementia, was determined by both the History and Physical and the Minimum Data Set to lack the capacity to make medical decisions. Despite this, the facility's Interdisciplinary Team (IDT) provided consent for the pneumococcal and RSV vaccines, rather than obtaining consent from the resident's responsible party. Interviews and record reviews revealed that the responsible party's contact information was available in the hospital referral packet at the time of admission, but the facility did not utilize this information when obtaining consent. Staff confirmed that facility policy requires the responsible party to provide consent when a resident lacks decision-making capacity and has an appointed representative. The failure to involve the responsible party in the consent process resulted in the resident not being fully informed or able to exercise the right to refuse treatment as required by facility policy.