Failure to Inform Resident of Rights and Rules Upon Admission
Summary
The facility failed to ensure that a resident was informed of their rights and the facility's rules upon admission. Resident 225, who has diagnoses including type 2 diabetes mellitus, bipolar disorder, and hypertension, was admitted to the facility and was responsible for herself. During an interview, the resident indicated that she had not received any orientation or information about her rights and the facility's rules since her admission. A review of her records showed that while a Consent to Treatment Form was signed, there was no documentation that her rights or the facility's rules had been discussed with her. The facility's Administrator later confirmed that the admission paperwork, including resident rights, was only reviewed with the resident after the issue was identified, due to the Admissions Director being on unexpected leave and the staff covering still trying to catch up.
Penalty
Resources
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The facility did not review Resident Rights during Resident Council meetings for several months, as confirmed by resident and staff interviews and review of meeting minutes. Multiple residents who attended these meetings were unaware of where to find information about their rights, and the omission was attributed to a change in agenda forms by the Activities Director.
The facility did not provide ongoing communication about resident rights during Resident Council meetings, as confirmed by a review of meeting minutes and interviews with a resident and the Activity Director. This omission had the potential to affect all residents in the facility.
Failure to Review Resident Rights During Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were informed of their Resident Rights, as required by policy. Review of Resident Council meeting minutes over an 11-month period showed that Resident Rights were not discussed during these meetings. Interviews with several residents confirmed that they were not aware of where to find information about their rights and that these rights had not been reviewed during Resident Council sessions. The Activities Director acknowledged that Resident Rights were omitted from the meetings due to a change in the agenda forms. Facility policy indicated that Resident Rights should be reviewed during Resident Council meetings, but this was not done, affecting multiple residents who attended these meetings.
Failure to Communicate Resident Rights During Council Meetings
Penalty
Summary
The facility failed to provide ongoing communication to residents regarding their rights, as evidenced by a review of Resident Council meeting minutes over a period of several months, which showed no documentation of resident rights being discussed. An interview with a resident confirmed that staff did not review resident rights during Resident Council meetings. Additionally, the Activity Director, who had been conducting the meetings since September 2024, acknowledged that she was not discussing resident rights with residents and only became aware of the requirement to do so in March 2025. This lack of communication regarding resident rights had the potential to affect all residents in the facility, which had a census of 44 at the time of the survey.
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