Failure to Obtain Required Protective Placement Documentation for Resident with Guardian
Penalty
Summary
The facility failed to ensure that a resident with a legal Guardian had the required court-ordered protective placement documentation, as mandated by State Statute Chapter 55.03(4) for residents whose nursing home stay exceeds 90 days. The resident, who had diagnoses including traumatic brain injury, restlessness and agitation, anxiety, and mood disorder, was admitted with Michigan Guardian paperwork for healthcare decisions. Despite the resident's intact cognition as indicated by a BIMS score of 14 out of 15, the medical record did not contain evidence of the necessary protective placement documentation. Staff interviews and record reviews revealed that the Social Services Director notified the Aging and Disability Resource Center Staff (ADRCS) about the need for protective placement and provided communication records. ADRCS requested specific guardianship documents from the facility, but these were not provided. Further, ADRCS identified that the protective placement paperwork should be filed in the county where the resident previously resided, and attempts to obtain the necessary documents from that county were made. However, the required protective placement documentation was not present in the resident's record at the time of the survey.