Failure to Inform Resident of New Diagnosis and Treatment Options
Penalty
Summary
A deficiency occurred when the facility failed to inform a resident with multiple complex diagnoses, including type 2 diabetes mellitus, chronic heart failure, and end stage renal disease, of a new diagnosis of Clostridium Difficile. The resident, who was cognitively intact and dependent on staff for activities of daily living, was not notified of the diagnosis, was not offered available treatment options, and did not receive education regarding the risks of refusing treatment. Documentation showed that the resident had a history of refusing medications and was on hospice care, but there was no evidence that the resident was informed about the new diagnosis or the rationale for antibiotic therapy at the time the positive lab result was received. Interviews with facility staff confirmed that the standard practice would be to inform the resident of a new diagnosis, discuss treatment options, and provide education on the consequences of refusal. However, both the clinical record and staff interviews indicated that this process did not occur for the resident on the date of the positive Clostridium Difficile result. The facility's own policy required staff to explain the negative effects of refusing medications and to document refusals, but this was not followed in this instance.