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F0551
D

Failure to Ensure Healthcare Decisions Made by Properly Delegated Representatives

Oshkosh, Wisconsin Survey Completed on 05-14-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the right to make healthcare decisions was exercised only by individuals properly delegated by the resident, in accordance with applicable law, for two residents. In the first case, a resident with moderate dementia and an activated Power of Attorney for Healthcare (POAHC) had a designated agent who resigned. The facility allowed a family member, not listed as a healthcare agent in the POAHC document, to make healthcare decisions and sign medical consents for the resident. Staff interviews confirmed that the family member was not authorized to act as the healthcare agent, and the alternate agent listed in the POAHC was not contacted or involved. In the second case, another resident with moderate cognitive impairment and an activated POAHC was admitted with documentation confirming incapacity and the activation of their healthcare agent. Despite this, the facility had the resident, who was deemed incapacitated, sign multiple healthcare consent forms, including medication consents, a CPR directive, and a vaccine consent. Staff confirmed that the resident's POAHC should have been the one to sign these documents, not the resident themselves. Both incidents demonstrate that the facility did not follow its own policy or state law regarding the delegation of healthcare decision-making authority when a resident is deemed incapacitated. The facility failed to ensure that only the designated healthcare agent, as specified in the POAHC, was making or authorizing healthcare decisions for these residents.

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