Failure to Obtain Informed Consent from Resident with Decision-Making Capacity
Penalty
Summary
The facility failed to ensure that a resident, who was determined to have the capacity for informed medical decision-making, was given the opportunity to review and sign documents related to their medical care. Upon admission, consent forms for services such as audiology, eye care, podiatry, dental, behavioral health, vaccination education, psychotropic medication, and the MOLST (Medical Orders for Life Sustaining Treatment) were all signed by the resident's representative, despite the resident's healthcare proxy not being invoked and the resident being capable of making their own decisions. The facility's own admission procedures require that residents who are capable should be provided with information and the opportunity to execute advance directives and other consents themselves, with documentation in the medical record. Record review showed that the resident had a mild cognitive impairment but was able to communicate in English and Spanish, and the social worker confirmed with the hospital that the resident's healthcare proxy had not been activated. Interviews with facility staff, including the social worker and the assistant director of nursing, confirmed that the consents should have been signed by the resident, not the representative. The failure to follow proper procedures resulted in the resident not being fully informed or able to participate in decisions regarding their care and treatment documentation.