Inappropriate Physician Order for Healthcare Decision-Making Capacity
Penalty
Summary
The facility failed to ensure that a physician's order regarding a resident's capacity to make healthcare decisions was appropriate and based on a thorough evaluation. The physician documented that the resident was incapable of making healthcare decisions, citing cerebral palsy as the reason, without further explanation or evidence of mental incapacity. Record review showed the resident had a diagnosis of cerebral palsy, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition. The resident's Brief Interview for Mental Status (BIMS) score was 9, indicating moderate cognitive impairment, but staff interviews revealed that the resident was able to make his wants and needs known and had clear speech. Multiple staff members, including Social Services, Medical Records, and the Director of Nursing, confirmed that the resident appeared alert, oriented, and capable of communicating effectively. The physician later acknowledged that cerebral palsy is primarily a physical condition and, in this case, should not have been used as the sole basis for determining mental incapacity. The physician's order was not supported by a comprehensive assessment of the resident's decision-making capacity, leading to an inappropriate assignment of a healthcare decision maker.