Failure to Provide Written Notice of Facility Rules Regarding Private Companions
Penalty
Summary
The facility failed to provide residents or their representatives with written information regarding facility rules about private companions not being permitted to provide direct care to residents. Although the facility's policy states that a written description of resident rights will be provided upon admission and upon request, interviews confirmed that only verbal information was given about the restriction on private aides providing direct care. This omission was identified during a review of facility documentation and staff interviews. This deficiency was identified in the context of a resident with dementia, hypertension, and atrial fibrillation who experienced a fall in their room. The incident report revealed that a private 1:1 aide, who was present to sit with the resident, attempted to transfer the resident from bed to wheelchair and subsequently lowered the resident to the floor. The nurse later informed the aide that the resident required a two-person transfer due to their condition. The lack of written communication regarding the facility's rules for private aides contributed to the incident.