Failure to Notify Guardian of Significant Change in Treatment for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to notify the legal guardian of a resident with severe cognitive impairment and a legal guardian regarding significant changes in treatment options for ongoing right knee pain due to chronic osteoarthritis. The resident, who had a BIMS score of 00/15 indicating severe cognitive impairment, repeatedly expressed pain and emotional distress related to her right knee. Despite multiple medical evaluations and documentation of her ongoing pain and inability to participate fully in physical therapy, the facility did not contact the guardian to discuss or obtain consent for potential pain management interventions, such as a cortisone injection, for nearly seven weeks after admission. Throughout this period, medical records show that the resident was offered a cortisone injection several times but declined due to fear of needles and limited understanding of the procedure, as noted by her providers. The lack of timely notification to the guardian meant that alternative consent for pain management was not pursued, and the resident continued to experience pain and emotional distress. Documentation of guardian notification and consent for the injection was not present until a progress note dated almost seven weeks after admission.