Failure to Provide Sufficient Information for Informed Refusal After Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident representative was fully informed, in advance and in sufficient detail, of the resident’s condition, the risks and benefits of proposed treatment, and available treatment alternatives so that an informed decision could be made about care. The resident involved had COPD and dementia and had an admission agreement signed by a designated resident representative, who was identified as the responsible party, substitute decision maker, and primary emergency contact. The admission agreement and resident rights documents specified that the resident or representative had the right to be fully informed in understandable language about the resident’s total health status, to participate in treatment decisions, and to be informed in advance by a physician or other practitioner of the risks and benefits of proposed care and treatment alternatives. On the date of the incident, the resident experienced an unwitnessed fall from standing to the floor with a head strike, resulting in a large mass on the head. An external APN evaluated the resident via clinical review and video observation and documented that the resident had a fist-sized mass in the parietal area of the head, was taking aspirin and Plavix, and had diagnoses including dementia. The APN assessed the situation as an acute, critical problem, documented localized swelling, mass, and lump of the head, and determined that the resident required a CT scan to rule out an acute intracranial hemorrhage. The APN obtained physician orders for transfer to the emergency department for further evaluation. A nurse’s progress note documented that the resident fell, struck the back of the head, and that an external APN ordered transfer to the emergency department. The note recorded that the resident representative was informed of the order and declined the transfer. However, the documentation did not show that the resident representative was told that the resident had sustained a head strike, had a large head mass, or that the condition had been assessed as critical. The note also did not document that the representative was informed that the transfer was recommended to allow diagnostic evaluation, including a CT scan, or that the risks associated with refusing transfer after a head injury were explained. In a subsequent interview, the resident representative stated she was told only that the resident had fallen and that an APN had written an order to send the resident to the emergency department, and that facility staff indicated they did not think transfer was necessary; she reported not being informed of the head strike, the size of the mass, the critical assessment, or the concern for intracranial hemorrhage. Staff interviews and record review confirmed there was no documentation that these critical findings, risks, and treatment rationale were communicated, resulting in the resident representative not receiving sufficient, detailed information to make an informed decision about the resident’s care. During an interview, the Nursing Home Administrator was unable to provide any documentation demonstrating that the facility ensured the resident representative received the APN’s findings or a detailed explanation of the risks, benefits, and alternatives related to the recommended emergency department transfer. Specifically, there was no documented evidence that the representative was informed that the resident’s condition was critical, involved a significant head injury, and required emergency evaluation to rule out intracranial hemorrhage. This lack of documented communication and failure to provide detailed information to the resident representative prior to the refusal of transfer constituted the facility’s failure to ensure the representative could make an informed decision regarding the resident’s treatment options, as required by resident rights and facility policy.
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