Failure to Address Communication Deficits in Resident Care Plan
Summary
The facility failed to ensure that a resident with communication deficits had appropriate interventions to accommodate their needs and abilities. The resident, who was admitted with diagnoses including cerebral infarction, hemiplegia, and dysarthria, had impaired cognition and speech intelligibility issues. Despite these challenges, the resident's care plan did not adequately address the communication barriers, as evidenced by the lack of communication devices like a whiteboard in the resident's room and inconsistent staff awareness of the resident's communication needs. Observations and interviews revealed that the resident had significant difficulty being understood due to slurred speech and hearing impairment. Staff members, including a CNA and a speech therapist, noted the resident's challenges in communication, yet there was no consistent use of recommended communication aids such as a whiteboard. The speech therapist had informed nursing staff about the need for such aids, but this was not reflected in the care plan or consistently implemented in practice. Interviews with facility staff, including the Director of Nursing and the MDS coordinator, highlighted discrepancies in the assessment and documentation of the resident's communication abilities. The MDS assessment inaccurately coded the resident's speech as clear, despite evidence to the contrary. The lack of a comprehensive care plan addressing the resident's communication deficits posed a risk of miscommunication, potentially affecting the resident's ability to express needs and preferences effectively.
Penalty
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Resident mail was opened and not delivered to a cognitively intact resident with quadriplegia and dependent ADLs. Staff said they were trained to open Medicaid, Medicare, and Social Security mail, scan it into the record, and file it instead of giving it to the resident, and there was no consent or care plan authorizing this. The resident reported missing notice of a service increase and receiving a back bill she did not know how to pay.
Resident Mail Delivered Opened: The facility failed to ensure that residents received mail unopened. In interviews, several residents said they had received opened mail and wanted it delivered unopened. The AD said she did not open mail before handing it out, while the ADM said he, the AD, and the BOM provided mail service and that he opened some mail, including Medicaid-related mail and items that might contain checks. The facility admission agreement and resident rights policy reflected that residents could receive mail directly and had a right to privacy and confidentiality of written communications.
Failure to protect privacy in resident mail and packages. Two residents reported that staff opened their mail or Amazon packages without consent before delivering them, including one cognitively intact resident with a BIMS of 15. Staff acknowledged opening packages due to a prior concern about prohibited items, and the NHA stated resident privacy should be honored.
Failure to deliver resident mail on Saturday. During a resident council meeting, several residents stated they did not receive mail on Saturdays. An S7HR confirmed mail was delivered to the facility on Saturday but was not given to residents until Monday after office staff sorted it, and an S6ADM confirmed residents should have been receiving mail on Saturday.
Resident Telephone Access and Privacy: The facility failed to provide residents on two nursing units with a functional telephone in a private location for confidential calls. A portable phone on the second floor had no dial tone and had not worked for an extended period, and on the third floor there had been no functioning cordless phone for more than a year. Residents instead used the nurses' station landline, where conversations could be overheard, or the Nursing Supervisor's cell phone.
Failure to Deliver Resident Mail on Saturdays A resident who enjoyed receiving mail stated he/she did not know mail was delivered on Saturdays. The Activities Director said she delivered mail Monday through Friday but was unsure who handled Saturday delivery, and the Administrator confirmed mail was not distributed on Saturdays.
Resident Mail Opened and Not Delivered
Penalty
Summary
The facility failed to ensure a cognitively intact resident with quadriplegia, reduced mobility, and a sacral pressure sore had reasonable access to her mail and privacy in receiving it. Resident #2’s quarterly MDS showed a BIMS score of 15/15, and the record contained no care plan or admission packet permission authorizing the facility to open her mail. During interview, the resident stated staff opened her Medicaid mail, scanned it into the computer, and placed it in a file instead of delivering it to her. The receptionist stated she had been trained by the regional BOM and Regional Accounts Manager to open Medicaid, Medicare, and Social Security mail and upload it to the electronic record, and that the residents were not given those letters but instead had them placed in a file or binder. The Administrator stated the facility could not distinguish facility mail from resident mail and believed the mail was duplicated information, while a resident in a group interview stated financial mail had been opened. Resident #2 reported she did not receive notice of an increase in services and had a back bill she did not know how to pay, and she remained upset that her mail had been opened and not delivered to her.
Resident Mail Delivered Opened
Penalty
Summary
The facility failed to ensure residents had the right to send and receive mail and to receive their mail unopened. During a confidential group interview, 3 of 11 residents stated they had received mail already opened and said they wanted to receive it unopened. The residents stated they did not know why some of their mail was opened before it was delivered and that they did not like it. During interviews, the AD stated she had recently started passing out mail and said she did not open any mail before giving it to residents. The ADM stated he, the AD, and the BOM provided mail service to residents, and he acknowledged that he opened some residents' mail before giving it to them. He stated the BOM and he processed Medicaid mail for residents and that the facility's admission agreement allowed the facility to open resident mail. The BOM stated she only opened and kept mail from Social Security that was not addressed to the resident, and that all other mail she delivered was unopened. The facility's admission agreement included an option for all mail to be given directly to the resident, and some residents had selected that option. The facility policy stated residents have the right to send and receive mail and to privacy and confidentiality of written communications.
Failure to Protect Privacy in Resident Mail and Packages
Penalty
Summary
The facility failed to ensure residents had privacy in their written communications when receiving mail and packages for two residents. The facility policy stated that residents have the right to privacy in written communications and to send and promptly receive unopened mail and other materials, and that mail should be delivered unopened or postmarked within 24 hours. Despite this, Resident 4 reported during the resident council meeting that staff had opened her mail because they thought it was insurance papers and then returned it to her opened with a note, and she stated she did not give consent for staff to open her mail. Resident 110 also reported that staff opened her Amazon packages without her present before giving them to her. She stated that her friend ordered snacks, hygiene items, and clothing for her, that she could track when the packages were delivered, and that she sometimes did not receive them until two or three days later and had to ask staff for them. She said staff told her they needed to check for knives because of a prior issue with another resident ordering them, and she stated she did not consent to staff opening her packages. Her record showed a BIMS score of 15, indicating she was cognitively intact. An Activities Assistant confirmed she had previously opened Resident 110's packages before giving them to her, and the NHA stated resident privacy should be honored and packages should not be opened by staff prior to delivery.
Failure to Deliver Resident Mail on Saturday
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods by not providing residents their mail on Saturday. During a resident council meeting, Residents #7, #15, #21, #28, and #63 each stated they did not receive any mail on Saturdays. An interview with S7HR confirmed that residents received mail only on weekdays, Monday through Friday, and that although mail was delivered to the facility on Saturday, residents did not receive it until Monday morning after office staff sorted through it. S6ADM later confirmed that residents should have been receiving their mail on Saturday.
Resident Telephone Access and Privacy
Penalty
Summary
The facility failed to ensure residents had reasonable access to functional telephones that afforded privacy during telephone communications on two nursing units. During an environmental tour of the second-floor nursing unit, a portable black telephone was observed on a desk behind an enclosed office at the nurses' station, but it did not have a dial tone and was not functional. An RN stated the portable telephone had not worked for an extended period, and when residents requested telephone access, staff offered the Nursing Supervisor's cellular telephone. On the third-floor nursing unit, an LPN stated there had not been a functioning cordless telephone available for resident use for more than one year. Residents either used the landline telephone at the nurses' station, where conversations could be overheard by people in the surrounding area, or were offered the Nursing Supervisor's cellular telephone. No resident-accessible telephone was available in a private location for confidential telephone communications, and the NHA confirmed the facility did not provide residents on all nursing units with access to a functional resident telephone that afforded privacy during telephone communications.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure resident mail was delivered to residents on Saturdays. During a Resident Council meeting, Resident 5, who was admitted in 5/2024 with diagnoses including encephalopathy, stated that he/she enjoyed receiving mail and did not know mail was delivered on Saturdays. In an interview, the Activities Director stated that she delivered mail to residents Monday through Friday but was unsure who distributed mail on Saturdays. The Administrator later confirmed that mail was not distributed to residents on Saturdays.
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