Failure to Ensure Residents' Capacity for Arbitration Agreement
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident R147 and Resident R151, had the capacity to understand the terms of a binding arbitration agreement. Resident R147 was admitted with a diagnosis of non-traumatic brain dysfunction and cognitive communication deficit, scoring a 12 on the Brief Interview for Mental Status (BIMS), indicating moderate cognitive impairment. Despite this, the resident signed the arbitration agreement shortly after admission. Similarly, Resident R151, who was admitted with altered mental status and scored a 2 on the BIMS, indicating severe cognitive impairment, also signed the arbitration agreement. Both agreements were signed by the facility's Admission Director, Employee E20. The deficiency was confirmed through a review of facility documents, resident clinical records, and staff interviews. The Director of Nursing, Employee E2, acknowledged that both residents had communication and cognitive deficits, which should have precluded them from being presented with the arbitration agreement. This failure to ensure residents' understanding of the arbitration agreement violated the regulatory requirements for entering into such agreements.
Plan Of Correction
This plan of correction is submitted to comply with federal regulations. This plan is not an admission of guilt, or wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. The facility cannot go back retroactively to correct the issue. The NHA/designee conducted a 30-day look back of new admissions to ensure residents that have signed the arbitration agreement have the capacity to understand the terms of a binding arbitration agreement. The NHA/designee educated the Admissions Director that if a resident lacks capacity, the resident cannot sign an arbitration agreement. The NHA/designee will audit new admissions arbitration agreements to ensure that the resident has the capacity to understand the agreement to sign it. Audits will be done weekly x 4 weeks, then monthly x 2 months. Results of these audits will be submitted to the quality assurance committee to determine if further action is required.