Failure to Notify and Involve Guardians in Therapy Initiation
Penalty
Summary
The facility failed to inform and include residents' legal guardians in the decision-making process for initiating physical and occupational therapy services for three residents. In each case, the legal guardian was not notified or consulted prior to the start of therapy, despite the residents being unable to make informed decisions for themselves. Interviews with the guardians revealed frustration and a lack of awareness regarding the initiation and goals of therapy services. Documentation review confirmed that there was no evidence of guardian notification or consent prior to the commencement of therapy for these residents. Staff interviews indicated that it was the facility's expectation and policy to obtain consent from the resident or their legal representative before starting therapy services, especially when the resident was not cognitively competent. However, in these instances, staff acknowledged that the required notifications and consents were not obtained as per policy. The facility's own policy emphasized the importance of valid consent and clear communication regarding treatment options, but records and staff statements confirmed that this process was not followed for the affected residents.