Failure to Assess Competency and Secure Guardianship for Severely Cognitively Impaired Resident
Penalty
Summary
A resident with severe cognitive impairment, diagnosed with schizoaffective disorder bipolar type, psychosis, and a manic episode, was admitted and later readmitted to the facility. The resident's Minimum Data Set (MDS) assessment documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment, and the psycho-social assessment noted severely impaired decision-making skills and no available family or psychiatric facility support. Despite these findings, the resident was listed as their own responsible party, and there was no documentation of a Power of Attorney (POA) or guardianship in the medical record. The facility's policy required referral to a psychiatrist for capacity assessment in such cases, but this was not done. Staff interviews confirmed that the resident could not make their own decisions and required a legal representative, yet no competency assessment was completed to determine the need for guardianship or a representative. The resident was ultimately discharged to an independent living facility based on their own verbal consent, despite staff acknowledging the resident's inability to make informed decisions. The facility failed to follow its own policy and state-specific laws regarding guardianship and consent for residents with impaired cognition.