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Resident Rights42 CFR §483.10(c)

F0552Right to be Informed/Make Treatment Decisions

F0552 requires residents to be fully informed of their health status and to be given the right to participate in decisions about their care, including the right to refuse treatment, in a manner they can understand.

Common Deficiency Examples

  • Resident not informed of a significant change in condition or treatment options
  • Informed consent not obtained or documented prior to a treatment change
  • Information not provided in a format/language the resident could understand
  • Resident's treatment refusal not honored or not properly documented

What Your Plan of Correction Needs

F0552 PoCs should show the communication gap and the fix to how information is delivered:

Gap identifiedspecific decision or information point where the resident wasn't adequately informed
Immediate actionresident/representative briefed and consent obtained where applicable
Systemic fixconsent/communication process update, including format/language accommodations
Monitoring planinformed consent documentation audits at a defined frequency
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