Failure to Obtain and Document Resident Consents for Care and Treatment
Penalty
Summary
The facility failed to ensure that residents were fully informed and provided with the opportunity to make decisions regarding their care and treatments upon admission. For three of four sampled residents reviewed for advance directives, there were unsigned consent forms for psychoactive medications, emergency use of potassium iodide, mental health services, and vaccinations. Despite residents being cognitively intact and capable of making their own decisions, the required consents were not obtained or documented, and the care plans did not reflect that permissions for these treatments had been secured. In one case, a resident was administered an antipsychotic medication without a signed consent, and the facility acknowledged that, in the event of a nuclear emergency, potassium iodide would have been administered without consent. Interviews with the Director of Nursing Services revealed that it was the responsibility of the LPN or nurse supervisor to ensure that consent forms were signed within two days of admission, but this process was not followed, resulting in unsigned forms remaining in the residents' charts for extended periods. Additionally, the facility was unable to provide a policy for obtaining resident consent prior to treatment, and admission documentation and checklists were incomplete, with blank areas for vaccine dates and missing signatures from residents or their responsible parties.