Other·August 3, 2022

F0552 §483.10(c)(1)(4)(5) Right To Be Informed/make Treatment Decisions §483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. On December 21, 2021, an unannounced visit was conducted at the facility to investigate a complaint regarding resident rights, including the right of a resident (through its responsible person, RP) to receive or refuse health care services before services are rendered. The complaint alleged the facility did not verify consent before facilitating a service. Resident 1's right to be informed was not ensured by the facility prior to the facilitating a telehealth visit between the resident and an outlying psychology provider, which did not provide the RP with advance information about the doctor visit or afford the RP an opportunity to accept or decline care. The facility failed to comply with the federal requirements regarding resident rights for planning and implementing care, when it coordinated and facilitated a doctor visit for psychological evaluation without notifying the RP. Resident 1 was admitted to the facility in March 2019, for diagnoses that included muscle wasting, hearing loss, dementia (a cognitive disorder affecting memory), and Alzheimer's disease (a progressive disease that destroys memory, thinking, and communication skills). Resident 1's Order Summary Report, dated 4/2020, indicated the resident was "not capable of decision-making". A review of Resident 1's Advance Directive (AD), executed 2/24/2015, indicated Resident 1 designated RP as her "agent," to make "health care and personal care" decisions when the resident became incapable. During an interview on 2/10/22, at 12:27 p.m., the DON stated a resident's duly signed admission agreement indicated appropriate consent to receive care and services, generally, for all future care and services rendered to a resident in the facility. The DON stated psychological services were ancillary services for the facility and all long-term residents were evaluated by a nurse practitioner to determine each resident's need for psychosocial help. During an interview on 3/10/22, at 1:38 p.m., the DON stated the facility did not have a protocol for obtaining consent for ancillary services rendered in the facility, as a resident or RP would have already provided consent upon signing the resident's admission agreement. During a review of electronic correspondence between CDPH and the Administrator, dated 5/3/22, at 1:16 p.m., the Administrator indicated: "We don't have a specific policy outlining" the consent process when facilitating psychological services because "psychological services" are considered an "other ancillary service," and a signed "consent to treat" on admission encompassed consent for psychological services. During an interview on 4/26/22, at 3:34 p.m. the Director of Operations (DO) for the facility's contracted psychological services provider stated the provider's "clinicians talk to patients to verify they want the visit." The DO stated the facility should get "in touch with" the responsible party if the patient is not cognitively intact. During an interview on 5/3/22, at 2:28 p.m., the Assistant Director of Nursing (ADON) stated the facility maintained no verification-of-consent form for a resident or RP to sign, to verify consent had been provided prior to a resident receiving psychological services in the facility. During an interview on 5/3/22, at 3:12 p.m., Resident 1's RP stated facility staff had mentioned the resident's behavior had changed when interacting with the facility hairdresser, but facility staff did not mention or discuss a psychological evaluation for Resident 1 prior to facilitating the service on 5/21/20. During an interview on 5/4/22, at 10:08 a.m., the Administrator stated each RP was provided the opportunity to decline psychological services for a resident at the time the RP is notified. During a review of the medical record for Resident 1, the "Progress Notes," dated 3/4/20 at 2:20 p.m., the note indicated the facility "notified" Resident 1's RP of the resident's behavior "change in condition" when interacting with the facility's hairdresser. The note did not indicate the facility discussed a plan for psychological services with the RP. On 4/14/22, CDPH requested the facility to provide the physician order for Resident 1's 5/21/20 psychological visit. CDPH requested the document from the facility's Administrator, Social Services Director, and Medical Records staff. The facility did not provide the physician order requested. During a review of the medical record for Resident 1, the "Patient Visit Information" note, dated 5/21/20, indicated Psychologist C performed a 25-minute "diagnostic evaluation" of Resident 1 by telehealth on 5/21/20. During a review of the facility document on resident rights, dated 10/4/16, the document indicated: "As a resident of this nursing facility ... you have the right to be informed of, and participate in, your treatment, including the right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will furnish care." The document also indicated the resident has the right to be "informed in advance by the physician or other practitioner or professional ... of treatment and treatment alternatives or treatment options and to choose the alternative or option you prefer". In violation of the above cited standards, the facility failed to comply with the federal requirements regarding resident rights for planning and implementing care, when it coordinated and facilitated a doctor visit for psychological evaluation without notifying the RP. This violation had a direct or immediate relationship to the health, safety, or security of patients or residents.