Failure to Ensure Proper Representation for Non-Competent Resident
Summary
The facility failed to ensure that a resident, who was deemed non-competent, had proper documented representation to make medical decisions. The resident, who had diagnoses including epilepsy, Parkinson's disease, and dementia, was admitted without a conservatorship application despite being unable to understand and make decisions. A review of the resident's records showed that a public guardian was initially assigned to investigate the need for conservatorship in 2015, but no petition was filed due to a lack of imminent need. However, by 2020, the resident's condition had deteriorated, and they were unable to make decisions, yet no new application for conservatorship was submitted. Interviews with facility staff revealed that the resident had been hospitalized multiple times in 2024 and returned to the facility in a nonverbal and nonresponsive state. Despite this, the facility relied on two physician signatures on the resident's POLST to make decisions, which was not in line with the facility's policy for representation. The Director of Nursing acknowledged that a conservatorship should have been applied for when the resident was deemed non-competent. The facility's policy indicated that legal authority for health care decisions should include a court-appointed legal guardian or conservator, which was not in place for this resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia and multiple comorbidities had a notarized 2021 Durable Power of Attorney and a signed health care representative form naming a specific family member as agent, and repeatedly verbalized to the DON and Social Services that this was the desired health care representative, not another family member. The facility rejected the provided documentation as outdated, insisted on new court paperwork, and continued to recognize the other family member as the representative despite having no resident-signed documentation for that person. The clinical record was not updated to reflect the resident’s stated choice, and the emergency contact remained listed as the non‑chosen family member, contrary to the facility’s own resident rights policy.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
A resident with dementia and severe cognitive impairment was started on Seroquel 25 mg BID for agitation and mood stabilization without documented consent from the resident’s representative. Review of the medical record and MARs showed the antipsychotic was administered over multiple weeks, including a restart after a brief hold, with no evidence of obtained consent. In interviews, the prescribing physician and the DON confirmed that staff did not secure representative consent for this change in treatment.
A resident with a terminal brain condition was admitted from a hospital on hospice with one family member documented as responsible party, while another family member was listed as next of kin on PASRR paperwork. The facility relied on existing hospice documents and its internal system, which named the first family member as representative, and did not review conflicting records or ask the resident whom he wanted to represent him. The resident, who was documented as alert and oriented with moderate cognitive impairment, told staff he did not want hospice and wanted a different family member to be his responsible party, but the facility continued to recognize the originally listed family member as the representative without consulting the resident, contrary to its resident rights policy allowing residents to identify individuals to be included in care planning.
A resident with cirrhosis on hospice care and a PleurX catheter experienced ongoing leakage from the liver catheter, prompting the resident’s spouse to request transfer to the ER for evaluation. Nursing staff contacted a CRNP, who consulted with hospice and determined the resident did not need ER care and could be seen by hospice in the facility. Despite the spouse’s continued insistence on ER transfer, staff informed her they could not provide an order and that leaving would be against medical advice, rather than facilitating the requested transfer. A Regional RN later confirmed that the resident should have been sent to the hospital when the responsible party requested it, demonstrating a failure to honor the resident representative’s right to make treatment decisions.
A resident with severe cognitive impairment had a court-appointed guardian as responsible party. After the resident, who required assistive device and one-person assistance, fell while attempting to self-transfer, staff assessed the resident with no injuries and notified the guardian by phone. Later, the guardian called 911 requesting that the resident be checked and potentially transferred to the hospital. When 911 contacted the facility, staff reported the resident was being monitored and denied pain, and no EMS dispatch or hospital transfer occurred. There was no documented follow-up communication with the guardian to discuss the resident’s condition or the guardian’s expressed wish for emergency services, and the guardian was not given the opportunity to exercise the right to request hospital transfer.
Failure to Honor Resident’s Chosen Health Care Representative
Penalty
Summary
The deficiency involves the facility’s failure to acknowledge and honor a resident’s expressed choice of health care representative, despite the presence of valid legal documentation. The resident had diagnoses including dementia, anxiety, unspecified convulsions, depression, and end stage renal disease. A Durable Power of Attorney dated in 2021 identified a specific family member as the resident’s agent, and the document was notarized and witnessed. The resident’s MDS and care plan documented impaired cognition related to dementia, with interventions to communicate with the resident and family regarding capabilities and needs and to monitor changes in cognitive function and decision-making ability. A complaint filed by a family member stated that the resident and this family member attempted to provide the facility with a signed Appointment of Health Care Representative form from 2021 appointing that family member as the resident’s health care representative. The facility did not accept the form, told them it was outdated, and informed them that a new court-issued form would be required before the family member would be acknowledged as the health care representative. Interviews with the resident and the family member confirmed that the resident had clearly verbalized to facility staff, including the DON and Social Services, that the resident wanted this family member to be the health care representative and did not want another family member in that role, but the facility continued to recognize the other family member instead. The social worker acknowledged that the resident had expressed a desire to have the first family member as health care representative and that there was a signed appointment of health care representative dated 2021, though he believed it had the potential to expire. The SW also stated that the facility had no documentation signed by the resident naming the second family member as health care representative. The DON confirmed that at admission the facility did not acknowledge the resident’s choice, that there was nothing in writing designating the second family member, and that the facility had nonetheless continued to treat that person as the health care representative. Review of the clinical record showed it still listed the second family member as emergency contact and did not document the first family member as health care representative, contrary to the resident’s expressed wishes and the facility’s own policy on resident rights and designation of representatives.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Failure to Obtain Representative Consent for Antipsychotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to obtain consent from a resident’s representative before initiating an antipsychotic medication. The resident was admitted in October 2025 with dementia with psychotic disturbance and was assessed on 10/29/25 with a BIMS score of 6/15, indicating severe cognitive impairment. On 12/23/25, a physician (Staff #16) ordered Seroquel 25 mg twice daily, and on 12/26/25 documented that the resident was agitated, not tolerating nursing or therapy care, and that a short course of Seroquel would be started for mood stabilization. Review of the resident’s paper and electronic medical record showed no documentation that consent was obtained from the resident’s representative for the administration of Seroquel. Medication Administration Records showed that the resident began receiving Seroquel on 12/23/25 at 9:00 PM and continued to receive it twice daily through 1/27/26, when the medication was placed on hold for seven days. The February 2026 MAR showed that Seroquel 25 mg was restarted on 2/4/26 at 9:00 AM and continued until 2/6/26 at 9:00 AM. During interviews, Staff #16 confirmed that facility staff failed to obtain consent for the administration of Seroquel, and the Director of Nursing confirmed that staff failed to obtain consent from the resident’s representative for this change in treatment.
Failure to Verify and Honor Resident’s Choice of Representative
Penalty
Summary
The deficiency involves the facility’s failure to establish and honor the resident’s choice of representative/responsible party. A male resident with a terminal diagnosis of senile degeneration of the brain was admitted from a hospital with hospice orders and documentation listing one family member (Family Member #2) as the responsible party. The face sheet and hospice paperwork identified Family Member #2 as the responsible party and signatory for hospice services, while the PASRR Level I screening listed a different family member (Family Member #3) as next of kin. The resident’s history and physical documented that he was alert and oriented to person, place, and situation, though with significant forgetfulness and impaired insight. A BIMS assessment later showed a score of 8, indicating moderate cognitive impairment, but the entry MDS initially had no BIMS score. Family Member #3 reported that the resident had been placed on hospice by Family Member #2 prior to transfer and that she was notified only after the fact. She stated that at the current facility the resident told staff he did not want Family Member #2 as his responsible party because she did not treat him well, and that he did not have a power of attorney. She further stated that the facility did not consult the resident or family about who he wanted as his representative and simply continued the same responsible party designation from the hospital, based on the fact that the resident had lived with Family Member #2 before admission. During a care plan meeting, Family Member #3 voiced that she believed the resident did not need hospice, but was told that Family Member #2 was the next of kin and remained the designated representative. The Administrator stated that the facility relied on the hospice paperwork and information from the hospice agency, both of which identified Family Member #2 as the representative, and that the facility did not review the PASRR documentation or ask the resident whom he wanted as his representative. The Social Worker stated she relied on the facility system, which listed Family Member #2 as the responsible party, and was not aware of a different next of kin. She also reported that a BIMS assessment had been requested to better gauge cognition, but therapy did not complete it because the resident was on hospice. The resident himself stated he did not know how he ended up at the facility under hospice, reported that Family Member #2 left him there and did not want him back home, and clearly expressed that he did not want hospice services and wanted Family Member #3 to be his responsible party. The facility’s resident rights policy stated that residents have the right to identify individuals or roles to be included in the planning process, but the facility did not obtain or act on the resident’s expressed preference for his representative.
Failure to Honor Resident Representative’s Request for Hospital Evaluation
Penalty
Summary
The facility failed to honor a resident and responsible party's right to make informed decisions regarding treatment when a request for hospital evaluation was not followed. Facility policy on residents' rights and advanced directives stated that residents have the right to request, refuse, and/or discontinue medical or surgical treatment. The resident involved was cognitively impaired, required staff assistance for daily care, had cirrhosis of the liver, was receiving hospice services, and had a PleurX catheter with a care plan directing nursing staff to monitor the dressing and observe for signs of infection or worsening condition. A nurse's note documented that the resident's wife, acting as responsible party, requested that the resident be sent to the emergency room due to continued leaking from the liver catheter and asked to speak with the provider. The nurse contacted the CRNP with an assessment, and the CRNP consulted with the hospice nurse. They agreed the resident did not need to go to the emergency room and that the hospice nurse could assess the resident at the facility. When informed of this, the resident's wife insisted on taking her husband to the emergency room and verbally rejected hospice and the facility's position. Staff told her she had the right to go to the emergency room but could not provide an order for transfer and that leaving would be against medical advice because the provider wanted the resident to remain for hospice assessment. An interview with the Regional RN confirmed that if the responsible party requested hospital evaluation, the resident should have been sent, indicating that the facility did not honor the responsible party's request for transfer for evaluation.
Failure to Honor Guardian’s Right to Decide on Hospital Transfer After Fall
Penalty
Summary
Facility staff failed to honor the right of a resident’s court-appointed guardian to make decisions regarding transfer to the hospital. The resident had an MDS completed showing a BIMS score of seven, indicating severe cognitive impairment, and a court order documented that the resident was an incapacitated person with the son designated as permanent guardian and responsible party. After the resident, who required an assistive device and one-person assistance, attempted to self-transfer and was found on the floor, staff completed assessments and documented no injuries. Staff left a message for the responsible party about the fall and later documented that the responsible party returned the call and had no questions at that time. Subsequently, 911 dispatch contacted the facility to report that the resident’s responsible party had called 911, stating the resident had fallen and needed to be checked. Facility staff reported to 911 that the resident was being monitored per protocol and that the resident denied pain, and no EMS dispatch or hospital transfer occurred. There was no documentation of any follow-up or attempted communication from facility staff to the resident’s responsible party after the 911 call to discuss the resident’s condition or the guardian’s expressed desire for emergency services or hospital transfer. The record contained no evidence that staff provided the resident’s responsible party the opportunity to exercise the right to have the resident transferred to the hospital as requested.
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