Lack of Policy for Residents with Cognitive Impairment
Summary
The facility failed to have written policies and procedures regarding the visitation rights of residents with cognitive impairments who do not have a legal decision maker. This deficiency was identified in the case of a resident with severe cognitive impairment, who was admitted with diagnoses including altered mental status. The resident scored 3/15 on the BIMS assessment, indicating severe cognitive deficit, and was documented by a psychologist as having impaired judgment and insight, rendering her incapable of making her own healthcare decisions. Despite this, the resident was allowed to leave the facility on multiple occasions with unrelated persons without the consent of her family, who were listed as emergency contacts. Interviews with facility staff, including the Nursing Home Administrator, Social Work Director, and Nurse Practitioner, revealed that there were no existing policies or procedures for residents deemed not to have capacity and without a legal guardian or power of attorney. The staff acknowledged the absence of special orders or restrictions for such residents, and there was no precedent for contacting family members or appointing a guardian ad litem. This lack of policy and oversight led to the resident leaving the facility without appropriate consent, highlighting a significant gap in the facility's management of residents with severe cognitive impairments.
Penalty
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A resident’s long-time friend, a former employee previously terminated over an abuse allegation, was barred from entering the facility when she attempted to visit, and was told law enforcement would be called if she returned. Another individual confirmed awareness of the restriction, expressed no concern about the friend abusing the resident, and stated that the facility did not offer supervised or common-area visits. A staff member reported that any former employee terminated for an abuse allegation was categorically prohibited from returning to the building, without considering the resident’s relationship with the visitor, despite a visitation policy stating residents have the right to receive visitors of their choice and allowing only limited or supervised access when abuse is suspected or found.
Staff denied further visitation by two family members after a responsible party instructed the facility not to allow them to visit or receive medical updates, without confirming the resident’s own wishes. The resident, who had dementia but could express needs, later stated that these and other family members were allowed to visit and became sad upon learning they had been barred. The SSD acknowledged that facility policy allows family visitation based on the resident’s wishes and that staff should have asked the resident, but instead followed the responsible party’s directive contrary to the written visitation policy.
A cognitively intact resident with a history of substance abuse and prior overdose had an active care plan requiring monitoring for signs of substance use, but staff did not document such monitoring despite repeated episodes involving contraband and substance use. Over time, staff observed the resident with vape devices, pills, and marijuana-like smoke in the room, and later saw the resident smoking an unknown substance outside with a family member, yet the care plan was not meaningfully revised and no consistent monitoring was documented. The same family member later admitted giving the resident alcohol after the resident was found vomiting with alcohol odor and was hospitalized for alcohol intoxication, but the facility still allowed this visitor and others to continue unsupervised, unrestricted visitation, and did not inform the MD of earlier incidents or instruct staff on specific behaviors to monitor, contrary to the facility’s own visitation and substance use policies.
A resident with Parkinson’s disease, dementia, and moderate cognitive impairment stated he wanted unrestricted visits from his children, but staff followed a posted sign listing specific family members whose visitation was to be restricted per the POA. When a daughter arrived to visit, staff asked her name, informed her she was not allowed to see the resident based on the POA’s directive, and called the police when she refused to leave or provide ID; the police then told her she was trespassing. The Ombudsman reported that the POA was denying visitation and that there should not have been a barrier to the visit, while facility leadership acknowledged that the POA could not deny visitation and that the resident did want to see his daughter, yet the posted restriction and staff actions still prevented the visit.
A resident with severe cognitive impairment and multiple medical conditions was unable to receive visitors after 8:00PM due to the facility's locked front door and lack of staff response to the doorbell. Despite repeated requests from the resident's POA and discussions among leadership about possible solutions, no effective measures were implemented, resulting in the resident's visitation rights not being honored according to facility policy.
The facility did not have written policies or procedures for visitation rights, resulting in inconsistent and unclear restrictions on visitors for two residents—one with a guardian and severe cognitive impairment, and another who was cognitively intact. Staff were not consistently informed about visitor limitations, and the reasons for restrictions were not clearly communicated or documented, leading to confusion and distress among residents, staff, and family members.
Failure to Honor Resident’s Right to Chosen Visitor
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of her choosing. A long-time friend of the resident, identified as NF1, reported that when she first attempted to visit the resident after the resident’s admission, staff member B escorted her out of the building and told her that law enforcement would be called if she returned. NF1 had previously been employed by the facility approximately four years earlier and had been terminated due to an allegation of abuse toward a resident. The facility did not allow her to visit the resident in any capacity. Another individual, NF2, stated he was aware that the facility was not allowing NF1 to visit the resident and that he knew about the prior abuse allegation but was not concerned about NF1 abusing the resident. NF2 stated he wanted NF1 to be allowed to visit and that the facility did not offer supervised visits or visits in a common area. He was hesitant to raise the visitation issue with the facility because he was concerned it might change how the resident was treated. Staff member B confirmed that any employee terminated due to an abuse allegation was not allowed to return to the building for any reason, and that this restriction was applied without considering the resident’s history with the visitor. The facility’s visitation policy stated residents have the right to receive visitors of their choice and that limitations may include denying or limiting access to individuals suspected of abuse until an investigation is completed or abuse is found, but the facility applied a blanket prohibition in this case.
Failure to Honor Resident Visitation Rights Over Responsible Party Objection
Penalty
Summary
The facility failed to honor a resident’s right to receive visitors of their choosing when family members were denied further visitation based on instructions from the resident’s responsible party (RP) without confirming the resident’s wishes. The resident had been admitted with diagnoses including a UTI and unspecified dementia, and documentation indicated the resident could make needs known but could not make medical decisions and had impaired cognitive skills for daily decision-making. During a visit, two family members requested a medical update from the Social Service Director (SSD). After the SSD spoke with the RP, the RP instructed the facility not to provide medical updates or allow further visitation by these two family members. The facility then denied these family members further access to the resident. In subsequent interviews, the resident stated that the two family members, as well as any family members, had permission to visit and later expressed sadness upon learning that these family members had been denied visitation, stating that family members were their life, with tears observed. The SSD acknowledged that facility policy was to allow any family members to visit when residents permit it and that staff should have asked the resident whether the two family members were allowed to visit. The facility’s written visitation policy stated that residents may receive visitors subject to the resident’s wishes and the protection of other residents’ rights and safety. Despite this policy, staff relied solely on the RP’s direction and did not consult the resident, resulting in the violation of the resident’s visitation rights and the resident not receiving visits from the two family members.
Failure to Restrict and Monitor Visitor Access for Resident With Ongoing Substance Use Incidents
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor its visitation and substance use disorder policies for a resident with a known history of psychoactive substance abuse and prior fentanyl overdose. The resident, who was cognitively intact but dependent on staff for transfers and with impaired mobility, had an active care plan for substance use that called for monitoring for signs and symptoms of substance use and abuse, such as confusion, drowsiness, outbursts of anger, and mood changes. Despite this, there was no documented evidence over multiple months that staff monitored the resident for these signs as outlined in the care plan. The facility’s visitation policy allowed for limiting or supervising visitors who abused, coerced, or exploited residents or who had a history of bringing illegal substances into the facility, but the facility did not operationalize these restrictions for this resident. Multiple documented incidents showed that the resident possessed or used substances and smoking materials, often in the presence of a specific family member visitor. On one occasion, staff observed the family member staying almost every night in the resident’s room and notified the DON and police due to suspicious behavior, but there was no documented investigation to determine the source of contraband. On another date, staff found the resident with vape devices and Blue Chew pills; these items were removed and given to a family member, and a late entry note by the DON recommended ongoing monitoring due to the resident’s substance-related history. However, there was no subsequent documentation that the resident was supervised or monitored for suspicious behaviors or signs of substance use as recommended. Later, staff documented that the resident’s room smelled like marijuana while the resident was with a visitor, and both were educated on facility policy, but the care plan was not revised to add new interventions related to this event. Further incidents continued without changes to visitation practices or documented monitoring. A restorative nursing assistant reported seeing the resident outside the facility with the same family member, who appeared to place an unknown smoking material to the resident’s mouth; this was reported to nursing and the administrator, and an order was obtained to closely monitor the resident for changes in level of consciousness, but there was no documentation that such monitoring occurred. Subsequently, the resident was found in his room vomiting, with foaming at the mouth and a smell of alcohol present; the family member at the bedside admitted giving the resident alcohol, and the resident was sent to the hospital and diagnosed with alcohol intoxication and alcohol abuse. When the resident returned from the hospital, there was no documentation that supervision or monitoring of the resident or the family member’s visits was implemented. Visitor sign-in records showed that the same family member and other friends continued to visit without restrictions or supervision. Interviews with the administrator, DON, nursing staff, and receptionist confirmed that no visitation restrictions or supervision were put in place for this family member, that there was no investigation into earlier contraband incidents, that the physician was not informed of key events, and that staff were not instructed on specific behaviors to monitor, despite the resident’s history and repeated episodes involving visitor-introduced substances.
Failure to Honor Resident’s Right to Receive Family Visitors
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to receive visitors of his choosing. The resident, who had Parkinson’s disease, unspecified dementia, and moderate cognitive impairment, reported that he had a blended family with three daughters and a stepson who served as his POA. He stated there had been internal family conflict, that his stepson did not get along with his daughters, and that the stepson had blocked his daughters from phone contact and visiting. The resident clearly stated there should not be any restrictions on any of his children visiting him. Despite this, a sign was posted at the nurse’s station stating that, per the resident and his wife/POA’s request, specific daughters and their spouses, as well as another family member, were to have their visitation restricted and that police could be contacted if they refused to leave. A daughter reported that she drove several hours to visit her father and, upon arrival, was told by staff she was on a list of people not allowed to visit per the POA; staff then called the police, who informed her she was trespassing and could not be there. The Ombudsman stated that the POA was denying visitation, that the facility believed there was to be no contact, and that there should not have been a barrier to the visit. Facility staff, including the receptionist and an RN, described following the posted note by asking visitors for their names, denying the daughter access, and calling the police when she refused to leave or provide identification. The RN stated the note restricting visitation was put up after a prior disturbance involving the daughter and that the POA had said to restrict visitation for these individuals. The Administrator and Director of Operations both acknowledged that the POA could not deny visitation and that visitation ultimately depended on the resident’s wishes, which were that he wanted to see his daughter, yet the posted restriction and staff actions continued to deny the daughter’s visit based on the POA’s request.
Failure to Ensure 24-Hour Visitation Access
Penalty
Summary
The facility failed to ensure that residents had unrestricted access to visitors of their choosing at any time, as required by federal and state regulations and the facility's own policies. Specifically, one resident with severe cognitive impairment and multiple medical diagnoses, including Alzheimer's Disease, vascular dementia, and major depressive disorder, was unable to receive visitors after 8:00PM because the front door was locked and staff did not respond to the doorbell. The resident's POA reported having to arrive before 8:00PM to visit and stated that repeated requests to facility leadership to address the issue were unsuccessful. The POA also attempted to alert staff through an electronic surveillance device in the resident's room, but staff did not respond to the front door. Interviews with the DON and Administrator revealed confusion and lack of implementation regarding after-hours visitor access. Although discussions had occurred about possible solutions, such as posting an on-call phone number or assigning a charge nurse to answer the door, no measures had been put into practice. Facility policies reviewed confirmed that residents are entitled to 24-hour visitation access, but these policies were not followed in practice, resulting in the resident's inability to receive visitors after regular hours.
Failure to Establish and Communicate Visitation Rights Policy
Penalty
Summary
The facility failed to have written policies and procedures regarding visitation rights, including the management of restrictions placed on two residents' visitors. The Administrator confirmed that there was no policy in place addressing visitation rights, and staff were not provided with clear guidance or communication about the reasons for visitor limitations. The facility's existing Resident Rights policy required informing residents and their representatives of their rights and responsibilities, but did not address the process for restricting visitors or communicating such restrictions to staff. For one resident with severe cognitive impairment and a legal guardian, the guardian provided a list of individuals who were not allowed to visit. This list was included in the resident's care plan and posted at the nurse's station, instructing staff to deny access to those individuals and contact authorities if necessary. However, staff interviews revealed confusion and lack of awareness about the restrictions, with some staff only discovering the list after incidents occurred. The rationale for the restrictions was not discussed with the guardian, and there was no documentation of official reasons or supporting court documents for the exclusions, despite allegations of past financial exploitation and family discord. Another resident, who was cognitively intact and had no guardian, was also affected when a family member was barred from visiting after an incident involving another resident. The family member was told by law enforcement not to return to the facility, which caused distress for the resident who had previously received frequent visits. Staff interviews indicated uncertainty about the authority and process for restricting visitors, and the chain of command was not consistently followed. The lack of a formal policy and clear communication led to inconsistent application of visitor restrictions and confusion among staff and visitors.
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