Failure to Inform Resident of Care Plan for Facial Laceration
Penalty
Summary
The facility failed to ensure that a resident was informed and involved in decisions regarding care for a facial laceration sustained during a surgical procedure. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and Parkinson's disease but demonstrated intact cognition with a BIMS score of 14, reported not being told about the care plan for the cut on her face. She expressed concern about potential scarring and a preference for ointment, but stated that the nurse had not communicated any plan of care. The Wound Care Nurse confirmed that while the resident's physician was notified and no new orders were given, she did not inform the resident about the absence of new treatment orders for the laceration. The Director of Nursing (DON) indicated that the facility's process should include completing a risk management form and notifying relevant parties, but acknowledged that she was not informed about the laceration because it was considered a scab. Facility policy requires that residents be informed of and participate in their treatment, including being told about risks, benefits, and alternatives. In this instance, the resident was not provided with information or choices regarding the treatment of her facial laceration, resulting in a failure to honor her right to self-determination and informed participation in her care.