Failure to Inform Residents of Leave Policies
Summary
The facility failed to inform residents both orally and in writing about the rules related to leaving the premises on pass prior to or upon admission. This deficiency was identified during interviews and document reviews, revealing that residents were not made aware of the process for going out on pass until they requested to do so. Specifically, Resident #3, who was admitted with a primary diagnosis of type two diabetes mellitus without complications, expressed feeling confined and uninformed about the ability to leave the facility. Interviews with staff, including a CNA and an LPN, confirmed that a physician's order was required for residents to leave on pass, but this information was not communicated to residents at the time of admission. The Director of Nursing acknowledged that residents were not informed of the rules and processes for going out on pass during admission, which is a resident right that should have been included in the admission packet. The facility's admission packet lacked documentation of these rules, and the facility's policy on Resident Rights and Responsibilities stated that residents should receive a written copy of their rights and the facility's rules upon admission. The policy on Out on Pass or Leave of Absence required a physician's order and interdisciplinary team decision for a resident to leave, but this was not communicated to residents as part of their admission process.
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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