Failure to Inform Resident of No-Cannabis Policy Resulted in Missed Medication
Summary
The facility failed to inform a resident and their representative of its policy prohibiting the administration of cannabis products prior to admission. The admission documentation did not include any information regarding the facility's stance on medical cannabis use. The resident, who had a physician's order for Cannabidiol Oral Solution to manage pain and seizures, was admitted without being notified that the facility would not permit the administration of this medication. As a result, the prescribed medication was not administered from the time of admission, and the order was later discontinued due to facility policy. Interviews with facility staff and the resident's representative confirmed that neither the resident nor their representative was made aware of the no-cannabis policy before or at the time of admission. The staff member responsible for reviewing medication lists at admission did not ensure that only medications permitted by facility policy were included. Additionally, when requested, the facility administrator was unable to provide a copy of the no-cannabis use policy during the survey.
Penalty
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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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