Failure to Ensure Resident Rights to Communication, Decision-Making, and Accurate Documentation
Penalty
Summary
The facility failed to complete and timely submit referrals for probate conservatorship for two residents who lacked decision-making capacity and had no responsible party or conservator. Both residents had severe cognitive impairments and were unable to make informed medical decisions, yet their records incorrectly listed them as self-responsible. The Social Services Director (SSD) did not initiate the conservatorship process because the Admission Records were not updated to reflect the residents' incapacity, resulting in a lack of oversight for their medical care and improper notification of changes, including during hospital transfers. Additionally, the facility did not ensure that the Minimum Data Set (MDS) accurately reflected residents' language preferences and need for interpreter services. For two residents, the MDS incorrectly indicated that they did not require an interpreter, despite their limited English proficiency and preference for communication in their native languages. Staff made assumptions about language preferences without verifying with the residents or their families, leading to communication barriers. Staff were also unaware of available interpreter services and had not received training on their use, further impeding effective communication. The facility also failed to provide a communication board for a non-verbal resident with aphasia, despite documentation in the care plan indicating the need for alternative communication tools. The resident was unable to express needs or participate in care planning due to the absence of a communication device. Staff acknowledged the lack of a communication board and recognized that the resident could not receive appropriate assistance without it. Facility policies required the provision of communication aids and staff training, but these were not implemented as needed.