Inaccessible Survey Results and Contact Information
Summary
The facility failed to ensure that previous survey results, State Hotline, and Ombudsman contact information were accessible to all residents. During a Resident Council meeting, members expressed their inability to locate the survey results and contact information for the Ombudsman and State Hotline. The survey results binder was located in the front lobby, which was not easily accessible to all residents, especially those who could not travel the .11 miles/580 feet from the 500 hallway/nursing unit to the lobby. Additionally, the contact information for the State Hotline and Ombudsman was placed at a height and in a format that was not accessible to residents in wheelchairs, as it was positioned approximately 5 feet high and not in large print. Interviews with the Director of Nursing (DON) and Activity Director (AD) confirmed the location of the survey results binder and the accessibility issues. The DON stated that the binder was visible to anyone entering through the front door, but did not acknowledge the distance issue. The AD noted that some residents were independent with their wheelchairs, but did not address the accessibility for all residents. An observation with the AD revealed that the contact information was not easily visible or readable for residents in wheelchairs, further contributing to the residents' complaints about not knowing how to contact the Ombudsman or access the State Hotline number.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure that residents were provided with and signed the necessary admission documentation, including the Consent to Treatment and Other Acknowledgements form and the Nursing Home Admission Agreement. This affected 41 residents, resulting in the facility not having consent to bill Medicare/Medicaid or to treat the residents.
Failure to Provide and Obtain Signed Admission Documentation
Penalty
Summary
The facility failed to ensure that residents admitted were provided with a description of the requirements and procedures for establishing eligibility for Medicaid, including the right to request an assessment of resources, as well as information concerning Medicare and Medicaid eligibility and coverage. This deficiency affected 41 residents whose records were reviewed for admission documentation. The review revealed that the Consent to Treatment and Other Acknowledgements form was not signed by the resident or their representative, nor was it witnessed by a facility representative. Additionally, the Nursing Home Admission Agreement, which describes the daily room rate, the right to an assessment of resources, and the authorization to bill Medicaid or Medicare for services rendered, was also not signed or witnessed as required. For instance, Resident #2 was admitted with diagnoses including hypertension, heart failure, and chronic kidney disease. The admission documentation for this resident lacked the necessary signatures on both the Consent to Treatment and Other Acknowledgements form and the Nursing Home Admission Agreement. Similar deficiencies were found in the records of other residents, such as Resident #3, who was admitted with hyperglycemia, diabetes, and hypertension, and Resident #5, who was admitted and readmitted with diagnoses including encephalopathy, chronic obstructive pulmonary disease, and hypertension. In each case, the required forms were not signed by the resident or their representative, nor were they witnessed by a facility representative. The issue was confirmed during an interview with Social Service Designee (SSD) #828, who acknowledged that the facility did not ensure the 41 residents had signed admission agreements. This lack of signed documentation resulted in the facility not having consent to bill Medicare/Medicaid for services rendered or a consent to treat while the residents were admitted. This deficiency represents non-compliance investigated under Complaint Number OH00151839.
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