Failure to Involve Resident Representative in Care Decisions and Informed Consent
Penalty
Summary
The facility failed to ensure that a resident's representative was given the opportunity to exercise the resident's rights during the care process. The resident in question was admitted with diagnoses including dementia, major depressive disorder, dysphagia, and muscle weakness, and was assessed to have a moderate cognitive deficit. Despite this, the facility did not attempt to contact the resident's family or friends to act as a representative or decision maker at admission or during the care process. Instead, the facility administrator was assigned as the resident's decision maker without documented efforts to involve or consult with the resident's family friend, who had previously acted as a patient advocate and was authorized to receive medical information. Multiple informed consent forms, including those for treatment, life-sustaining treatment, side/bed rail use, and psychotherapeutic drugs, were signed solely by the administrator. There was no evidence that the resident, the family friend, or any other representative was involved in or acknowledged these consents. The medical record lacked documentation of interdisciplinary team (IDT) meetings prior to obtaining these consents, and there was no indication that the resident, family friend, or a patient representative was consulted or involved in the decision-making process for these significant medical interventions. Interviews with facility staff, including the social services director, administrator, and director of nursing, confirmed that the required process for involving a patient representative and conducting IDT meetings was not followed. Staff acknowledged that no attempts were made to contact the resident's family, friends, or listed contacts to act as a decision maker or participate in care planning. Facility policies and state guidance reviewed during the survey emphasized the importance of involving a patient representative and conducting IDT meetings for residents lacking capacity, but these procedures were not adhered to in this case.