Failure to Deliver Mail on Saturdays
Summary
The facility, with a census of 48 residents, failed to deliver mail to residents on Saturdays, as identified during a resident council meeting. A resident reported the lack of mail delivery on Saturdays, which was confirmed by administrative staff. The facility's policy on residents' right to privacy in communication mandates that mail should be delivered to residents within 24 hours of receipt from the postal service. However, it was found that the Certified Medication Aides (CMAs), who were responsible for mail delivery on weekends, were not aware of this duty. During the investigation, it was discovered that the key to the mailbox, which was supposed to be kept in the medication cart for weekend use, was missing. Certified Medication Aide R was unable to locate the key and was unaware of the responsibility to deliver mail on Saturdays. Administrative Staff A acknowledged the oversight and mentioned the need for in-servicing the weekend staff regarding mail delivery responsibilities. This failure to deliver mail on Saturdays resulted in a deficiency in the facility's compliance with its own policy on residents' right to privacy in communication.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with dementia and anxiety, who required a private room for psychosocial needs, was unable to have private phone conversations due to the lack of a functional phone in their room and the use of a non-private nurses' station phone. Staff confirmed that conversations could be overheard, and facility policy referenced the right to private communications, but no designated private area was available.
A resident with a history of mental health diagnoses and intact cognition was unable to access a private area for telephone use, as facility phones were located in open, public spaces where conversations could be overheard. Staff interviews confirmed the lack of private phone areas, and facility policies requiring privacy for resident communications were not followed.
A resident with severe cognitive impairment did not have access to a working bedside phone, requiring her to use the nurse's station for family calls. Staff were unaware of alternative private phone options, and the facility's policy for private phone access was not effectively communicated or implemented, resulting in a lack of privacy for the resident's phone communication.
Residents did not consistently receive their mail on weekends, as confirmed by both resident interviews and staff statements. The facility's policy requires that residents have access to their mail, but this was not ensured during weekends.
Residents did not receive mail on weekends, as confirmed by multiple residents and the Business Office Manager, who stated that mail was only sorted and distributed Monday through Friday. This practice was inconsistent with the facility's policy granting residents the right to send and receive mail.
A resident who was cognitively intact and responsible for his own affairs reported that staff opened his mail without permission on several occasions. Staff interviews confirmed that mail was sometimes opened if it appeared to be insurance or a bill, and that mail was routinely reviewed by staff before being delivered, contrary to facility policy guaranteeing privacy in mail correspondence.
Failure to Provide Private Space for Resident Phone Conversations
Penalty
Summary
The facility failed to provide a private space for phone conversations, resulting in a deficiency affecting one resident out of three reviewed for reasonable access to privacy. The resident in question had diagnoses including dementia without behaviors, anxiety, and a history of stroke, and was assessed as having normal cognitive function. The resident's care plan indicated a need for a private room due to psychosocial needs. Observations revealed that the resident did not have access to a working phone in his room, and staff interviews confirmed that residents typically used the phone at the nurses' station, which was not a private area and could be overheard by staff, visitors, or other residents. Further investigation showed that the cordless phone at the nurses' station was not operational, and when a corded phone was found in the resident's room, it was not plugged in or functional. Staff confirmed that the resident made calls from the nurses' station and that conversations could be overheard, as evidenced by a staff member overhearing a personal conversation about cigarettes. The facility's policy referenced the right to private and unrestricted communications, but the lack of a designated private area and non-functional phones resulted in the resident's inability to have private phone conversations.
Failure to Provide Private Telephone Access for Resident
Penalty
Summary
The facility failed to provide a resident with reasonable access to a telephone in a private setting, as required by both facility policy and resident rights. Observations revealed that the designated telephone stations were located in open areas without doors or walls, allowing conversations to be overheard by staff, residents, and visitors. One resident, who had a history of paranoid schizophrenia, psychosis, anxiety disorder, and personality disorder, and who was cognitively intact and independent with ADLs, was observed making phone calls in these open areas. The resident expressed concerns about the lack of privacy, stating a preference for one phone location over another due to less foot traffic, but still noted there was no privacy available. Interviews with staff, including CNAs, an LPN, the Infection Preventionist, the Interim DON, and the Administrator, confirmed that the facility's phones were not portable and were situated in open, non-private locations. Staff acknowledged the lack of designated private areas for resident phone calls, and the Infection Preventionist reported occasionally offering his office for private calls. Facility policies reviewed indicated that residents were guaranteed the right to private communication, and that telephones should be located in areas offering privacy, but these policies were not being followed in practice.
Failure to Ensure Resident Privacy and Access for Telephone Communication
Penalty
Summary
Facility staff failed to ensure that a resident had privacy and reasonable access to telephone communication. Observation revealed that the resident's bedside phone was not plugged in and the phone jack did not have service, a situation that had persisted for several months according to the roommate. The resident, who had severe cognitive impairment and was rarely understood, was unable to be interviewed, but it was confirmed that she had a guardian and a family member involved in her care. When the resident received calls from her family, she had to go to the nurse's station to communicate, as her room phone was nonfunctional and lacked a cord to connect to the outlet. Staff interviews showed inconsistent knowledge about the availability of alternative phones for private use, with some LPNs unaware of any facility-provided cell phone and unable to locate one. The Unit Manager and Administrator were not aware that the resident's phone was unusable or that not all room phones had service. Facility policy required reasonable access to phones in a private area, but staff were not aware of the designated private phone options in the Social Services or Business Office. This resulted in the resident not having private access to phone communication as required.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure that residents received their mail on weekends, as required by their policy and resident rights. During interviews, several residents reported that mail was only delivered Monday through Friday, and not on weekends. The Activities Director confirmed that resident mail was not always delivered on weekends and stated that the weekend manager was responsible for this task. Review of the facility's Resident Rights policy indicated that residents have the right to send and receive mail, including privacy of such communication, but this was not consistently upheld for weekend mail delivery.
Failure to Provide Weekend Mail Delivery to Residents
Penalty
Summary
The facility failed to ensure that residents received their mail on weekends, as mail was only distributed from Monday through Friday. During a resident group meeting, several residents confirmed that mail was not delivered on Saturdays. The Business Office Manager also verified that she sorted mail only on weekdays and that the activities department distributed it to residents during that time, with no mail given to residents on Saturdays. Review of the facility's Resident Rights Policy indicated that residents have the right to send and receive mail in accordance with state and federal law, but this practice was not followed for weekend mail delivery.
Failure to Ensure Resident Privacy with Mail Correspondence
Penalty
Summary
The facility failed to ensure privacy for a resident regarding mail correspondence. A cognitively intact resident, who was his own responsible party, reported that staff had opened his mail on several occasions without his permission. During an interview, the Activity Director confirmed that staff opened the resident's mail if it appeared to be insurance or a bill. Further interviews with the Social Services Designee and the Business Office Manager revealed that mail was routinely reviewed by these staff members before being delivered to residents, and the Business Office Manager admitted to having opened some mail in the past. The facility's policy states that residents have the right to privacy in sending and receiving mail and email.
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