Failure to Inform Resident and Support Autonomy in Care Decisions
Penalty
Summary
The facility failed to notify a resident of treatment and healthcare information in accordance with his preferences, and did not ensure the resident had the opportunity to exercise autonomy regarding important aspects of his life. The resident, an older veteran, reported feeling unsafe due to not being kept informed about his lab test results and other treatment outcomes. He also stated that he was not invited to participate in his care plan meetings and that his requests for documentation from the facility were ignored, despite receiving such information from the VA hospital. A review of the resident's care plan showed that it included goals for involving the resident in care planning, promoting participation in care decisions, and informing him of changes in status or care needs. However, interviews with facility staff revealed that there was no consistent process for sending or documenting invitations to care plan meetings, and no evidence was provided to show that the resident had been invited. Additionally, the DON was unaware of the resident's desire to receive copies of his lab results, indicating a lack of communication and follow-through on the resident's expressed preferences.