Failure to Disclose Facility Limitations to Resident
Penalty
Summary
The facility failed to disclose and provide notice of special characteristics or service limitations to a resident or potential resident prior to admission, as required by §483.15(a)(6). This deficiency was identified during a review of the facility's admission policy, resident records, and staff interviews. The facility's policy, dated 12/9/24, mandates that such disclosures be made, but this was not adhered to in the case of one resident, referred to as Closed Resident Record CR1. Resident CR1, who had a history of mild to moderate Alzheimer's dementia and delirium, was referred to the facility from a hospital. The hospital referral noted the resident's behavioral issues, including wandering, verbal aggression, and visual hallucinations. Despite these documented concerns, the facility did not provide the necessary disclosures about its service limitations or special characteristics to the resident or their representative before the attempted admission. Upon arrival at the facility, Resident CR1 exhibited confusion and delusional behavior, refusing to go to her room and expressing a belief that she was supposed to be going elsewhere. The situation escalated to the point where Emergency Medical Services were called, and the resident was eventually returned to the hospital with the assistance of her family. Interviews with the Nursing Home Administrator and Director of Nursing revealed that they were unaware of the resident's behavioral history and acknowledged the failure to provide the required disclosures.
Plan Of Correction
1. Resident CR1 did not experience any negative outcomes. 2. An audit of admissions over the past 3 months will be conducted to determine if there are any residents with like clinical capabilities. 3. Facility's clinical capabilities were reviewed and updated. 4. Admissions team will be educated on updated clinical capabilities. 5. New admissions will be audited by DON/designee 2x/week for 3 weeks to monitor reasonable accommodations. 6. Results reported to QAPI for review and approval.