Failure to Involve Appropriate Decision Makers and IDT in Resident Care Planning
Penalty
Summary
The facility failed to ensure that a resident was effectively and efficiently cared for by the administrator, who acted as the resident's decision maker. The resident, who had diagnoses including dementia, major depressive disorder, dysphagia, and muscle weakness, was admitted without family involvement but had a family friend who had previously served as a patient advocate. Despite this, the administrator signed multiple informed consent documents for the resident's care and treatment, including consent to treat, POLST, side/bed rail use, and psychotherapeutic drug administration, without documented consultation with the resident, the family friend, or an interdisciplinary team (IDT). Interviews with the family friend, social services director (SSD), administrator (ADM), and director of nursing (DON) revealed that the facility did not follow the required process for unrepresented residents. The SSD and ADM acknowledged that the California Department of Aging had provided in-service training on the IDT process for unrepresented residents, which requires the inclusion of a patient representative and IDT review for medical decisions requiring informed consent. However, there was no documentation that such meetings or consultations occurred prior to the administrator signing the consents. The family friend, who was known to the resident and had been involved in his care previously, was not contacted or included in the decision-making process, despite the resident's agreement for the friend to receive medical updates and be involved in care. Record reviews and staff interviews confirmed that the administrator was not related to the resident and did not know him prior to admission. The facility's own policies, as well as state regulations, require that the resident's wishes and preferences be considered and that appropriate representatives be involved in care planning and consent processes. The lack of documentation and involvement of the IDT, patient representative, or the resident himself in these decisions constituted a failure to uphold the resident's rights and ensure care was provided in accordance with legal and regulatory requirements.