Failure to Honor Resident’s Right to Designate Recipients of Medical Information
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s responsible party did not make undelegated decisions and to honor the resident’s right to determine who could receive medical information. The resident was originally admitted with diagnoses including a UTI and unspecified dementia. The H&P documented that the resident could make needs known but could not make medical decisions, and the MDS showed impaired cognitive skills for daily decision-making, with the resident requiring partial to moderate assistance for ADLs. The facility’s records indicated the resident had a responsible party designated under a financial POA, not a medical POA. On a specific date, two family members visited the resident and requested a medical update from the SSD. The SSD, noting the family members were not listed on the admission record, denied the request after contacting the responsible party, who instructed the facility not to provide medical updates to those family members. The SSC confirmed they did not ask the resident for permission to share information with the family members. In a subsequent interview, the resident stated they were unaware that the family members had been denied medical updates, expressed sadness, and affirmed that these family members could receive medical information, stating that their family members were their life. The SSD later acknowledged that the POA on file was financial only and did not authorize medical decision-making, and that the facility should have asked the resident about their wishes, consistent with the facility’s Resident Rights policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.