Failure to Obtain Consent for Wound Biopsy in Cognitively Impaired Resident
Penalty
Summary
The facility failed to obtain proper consent prior to performing a wound biopsy on a cognitively impaired resident. The resident, who had severe cognitive impairment as documented in the Minimum Data Set, was admitted with multiple diagnoses including hemiplegia, aphasia, and respiratory failure. The wound care physician performed a biopsy on the resident's left shoulder after explaining the procedure to the resident, who reportedly indicated agreement by shaking his head and giving verbal consent. However, there was no documentation that the resident's family, who were responsible for making care decisions, were consulted or provided consent prior to the procedure. Interviews with facility staff confirmed that the resident was not capable of making decisions or providing consent for care or procedures. The social worker stated that the family had expressed a desire to be present for such decisions, and the family member confirmed that neither the resident's wife nor daughter was contacted for consent before the biopsy was performed. Review of the electronic medical record showed no documentation of consent from the family for the procedure.