Failure to Determine Decision-Making Capacity and Verify Legal Representation for Cognitively Impaired Residents
Summary
The deficiency involves the facility’s failure to implement and operationalize its policies and procedures for advance care planning, determination of decision‑making capacity, and verification of legal representation for three cognitively impaired residents. For one resident with dementia, psychosis, and anxiety, the MDS and multiple clinical notes over several months documented that the resident was rarely/never understood, alert only to self, highly cognitively impaired, and unable to make needs known. Psychiatric evaluations repeatedly described advanced dementia, profound cognitive impairment, and limited capacity for engagement, and a physician note explicitly stated the resident was cognitively impaired, unable to make decisions, and would need guardianship. Despite this, there was no documented competency assessment, no identification or activation of a legal decision maker, and no social services documentation addressing designation of a legal representative. The resident’s face sheet listed the resident as their own responsible party, and the granddaughter and daughters only as emergency contacts. During this same period, the facility obtained signatures on advance directive and psychotropic medication consent forms that were attributed to the resident, even though staff interviews confirmed the resident was not cognitively intact and did not have a DPOA or guardian. The advance directive form documented that the resident did not choose to formulate any advance directives, and psychotropic consents for Zyprexa and Remeron were signed and witnessed by staff, with illegible or inconsistent resident signatures/initials that appeared dissimilar from each other. Social services documented that the resident remained their own person and that the patient was their own decision maker, while other clinical notes described the resident as non‑verbal, unable to verbalize needs, unable to retain education, and exhibiting aggressive behaviors. Discussion with family about pursuing guardianship was not documented until approximately four months after admission, and social services acknowledged that no competency assessment was completed and that they did not address the lack of a legal decision maker because the resident was initially expected to be short‑term. For a second resident with a BIMS score of 0, severe cognitive impairment, aphasia, dysarthria, and dependence in ADLs, the MDS indicated the resident was rarely/never understood. The face sheet listed the resident’s mother as responsible party, but there was no documentation of competency assessment, guardianship, or DPOA in the EMR. Social services documented that the resident remained their own person and had no wishes to issue further advance directives, while also recording that the resident was nonverbal and that the mother refused psychiatric services on the resident’s behalf, even though she was not documented as a legal representative. When surveyors attempted to interview the resident, verbalizations were not understandable, and a CNA reported it was hard to know what the resident wanted and that they normally could not understand the resident. Despite this, an advance directive form in the EMR showed a clearly written resident signature that closely resembled the LPN witness’s signature; the LPN later denied that the signature was theirs or the resident’s and stated they did not know who signed the resident’s name. The LPN also reported the resident was admitted alone and was unsure who was making the resident’s medical decisions. For a third resident with heart disease and dementia, the MDS showed severe cognitive impairment and need for supervision to total assistance with ADLs. Two HCPs had deemed this resident incompetent to make medical decisions, and probate court documentation granted a named individual temporary guardianship for a defined period. However, no permanent or current guardianship documentation was present in the EMR after the temporary order expired, even though the face sheet continued to list this individual as the resident’s legal guardian. The Social Services Director stated that the resident had an active legal guardian and that guardianship documentation was maintained in the EMR, but when reviewed, only the expired temporary guardianship order could be produced. The director acknowledged they did not have current guardianship documentation and did not explain how they knew the individual was legally able to make decisions without proof. The facility’s own policies required ongoing assessment of decision‑making capacity, determination of when residents could no longer make their own health care decisions, and maintenance of documentation for guardianship or surrogate decision makers, but these processes were not carried out or documented for the three residents. The Administrator confirmed that social services was responsible for addressing competency and legal representation but was unable to explain why these issues were not addressed for the residents in question. The Administrator also acknowledged that the signatures on one resident’s advance directive form appeared similar and that it did not appear to be the resident’s signature, and agreed that no one else should sign for a resident unless requested and documented. The Administrator further confirmed that guardianship documentation should be scanned into the EMR and was informed that one resident’s guardianship documentation was not current, without providing further explanation. Overall, the facility did not follow its policies on advance directives, determination of advocates’ authority, and ongoing review of residents’ decision‑making capacity, resulting in the absence of timely competency determinations, lack of appropriate and legal representation for two residents, and lack of current guardianship documentation for the third resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Advance Directive Not Maintained in Resident Record: A resident with dementia, muscle weakness, and protein-calorie malnutrition had documentation indicating an advance directive was in the chart, but record review did not locate a living will or DPOA for health care. The CNO confirmed the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation: The facility failed to keep complete and accurate advance directive records for two residents. One resident's chart contained a representative-signed acknowledgement that did not specify the type of advance directive, and another resident's record had no signed acknowledgement showing that advance directives were discussed. The SSD stated she was responsible for the documentation and that one form was filled out incorrectly while the other resident's paperwork could not be found.
The facility failed to timely respond to changes in condition for two residents, including one with severe cognitive impairment and another with dementia, CHF, diabetes, and a history of UTIs. Family members and DPOAs reported concerns about confusion, agitation, pain, SOB, and other worsening symptoms, but hospital evaluation was delayed while staff waited for physician input. Both residents were later admitted to the hospital with serious infections and other acute conditions, including sepsis, pneumonia, and respiratory failure.
A facility failed to ensure that active physician orders matched residents’ POLST code status for three residents. One resident with COPD, A-Fib, and anxiety had a POLST indicating DNR but no active code status order; another resident with dementia, hypothyroidism, and HTN had a POLST indicating DNR but a physician order for CPR; and a third resident with COPD, respiratory failure, and diabetes had a POLST indicating DNR but no active code status order. The DON confirmed the records were inconsistent and that physician orders and POLST should match.
A resident with dementia with agitation, stroke, and PE had an advanced directive noted in a care conference review, but the document could not be found in the medical record. Staff later confirmed the resident did not have an advance directive on file.
Failure to offer a resident the opportunity to create an advance directive. Record review showed the resident had no advance directive on file, and the SS Director stated there was no documentation that education was provided or that any attempts were made to obtain one. The resident had HTN, CKD, and mild cognitive impairment.
Advance Directive Not Maintained in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's advance directive was maintained in the medical record for Resident #32, who was admitted with multiple diagnoses including dementia, muscle weakness, and protein-calorie malnutrition. The resident's care plan, revised 5/12/22, documented that the resident and appointed healthcare representative were to receive education regarding advance directives as needed, and a care conference evaluation dated 6/26/26 documented that the resident had an advance directive in the record. However, on 7/8/26, review of the medical record did not locate a living will or durable power of attorney for health care, and the CNO later confirmed that the record did not include an advance directive and the facility did not have a living will on file.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure documentation regarding advance directives was complete and accurate for 2 of 7 residents reviewed. A policy titled "Advance Directives and Refusal of Treatment" stated that upon admission the Social Services Designee should obtain a copy of any existing Living Will, Health Care Proxy, Durable Power of Attorney for Health Care Decisions, or other recorded declaration and enter a progress note regarding the existence of an advance directive. Resident #7 was admitted with diagnoses including hemiplegia and hemiparesis following a nontraumatic intracerebral hemorrhage affecting the right dominant side. The record contained a "Resident Rights & Advance Directive Acknowledgement" signed by the resident's representative that indicated the resident had an advance directive, but the form did not identify the type of advance directive. Resident #81 was admitted with end stage renal disease, and the medical record contained no signed acknowledgement showing that advance directives were discussed with the resident or representative. The Social Services Director stated she was responsible for advance directive documentation, that the form for Resident #7 was filled out incorrectly and should have been corrected, and that the missing paperwork for Resident #81 meant the facility would not know whether the resident had an advance directive.
Delayed Response to Changes in Condition and Family Requests for Hospital Evaluation
Penalty
Summary
The facility failed to timely provide requested medical evaluation and treatment for two residents with changes in condition. The deficiency was identified during review of Complaint #3035494 and involved delayed responses to worsening symptoms, resulting in delayed medical treatment, worsening of condition, and dissatisfaction with care. For one resident with diagnoses including Alzheimer's disease and other medically complex conditions, the record showed severely impaired cognition and inability to make decisions. A family member reported that the resident had a decline in health about a week before hospitalization, with severe UTI and stool impaction. The hospital record documented that the resident arrived from the nursing home via EMS with confusion and altered mental status that had worsened since several days earlier, and the ED physician suspected sepsis. The resident was febrile, tachycardic, had elevated white blood cell count and creatinine, and was diagnosed with proctitis, cystitis, sepsis, NSTEMI, and acute kidney injury. The urine culture was positive for gram-negative rods/Pseudomonas aeruginosa. For another resident with diagnoses including diabetes mellitus, a history of UTIs, CHF, Alzheimer's disease, and dementia, the progress notes showed family concerns about abnormal behavior, confusion, agitation, shortness of breath, congestion, lethargy, and shallow breathing. The resident's DPOA reported repeatedly expressing concern that something was wrong and requesting hospital evaluation, but the facility did not immediately send the resident out and instead contacted the physician first. The change-in-condition documentation noted altered mental status and respiratory symptoms, and the physician initially recommended a nebulizer treatment before later directing transfer to the ED. The resident was admitted to the hospital with bilateral pneumonia, acute hypoxic respiratory failure, likely demand ischemia, chronic diastolic CHF, fluid overload, severe anemia, and human metapneumovirus infection.
Physician Orders Did Not Match POLST Code Status
Penalty
Summary
The facility failed to ensure that active physician orders reflected residents’ end-of-life wishes as documented on their Pennsylvania POLST forms for three residents. Facility policy stated that residents are presumed to consent to CPR unless there is documentation in the medical record showing a DNR order, and that all DNR orders must be rewritten by the attending physician for each admission or readmission. Review of the clinical records showed that Resident R14 had diagnoses including COPD, A-Fib, and anxiety, and had a POLST indicating DNR, but the current physician orders lacked evidence of code status. Resident R38 had diagnoses including dementia, hypothyroidism, and high blood pressure, and had a POLST indicating DNR; however, a physician order dated in the record indicated CPR, creating inconsistency between the POLST and the physician orders. Resident R50 had diagnoses including COPD, respiratory failure, and diabetes, and had a POLST indicating DNR, but current physician orders also lacked evidence of code status. During interviews, the DON confirmed that Resident R14’s record lacked active physician orders reflecting code status and that Resident R38’s physician orders and POLST were not consistent, and further confirmed that resident physician orders and POLST should match regardless of the POLST.
Advance Directive Not Available in Resident Record
Penalty
Summary
The facility failed to ensure a resident exercised the right to formulate an Advance Directive. Review of the State Operations Manual, record review, and staff interview showed that Resident #5 had an advanced directive documented on a Care Conference Review Comprehensive dated 4/3/26, but the document could not be located in the medical record. Resident #5 was admitted and later readmitted to the facility with diagnoses including dementia with agitation, stroke, and pulmonary embolism. On 6/26/26 at 9:48 AM, a request was made for a copy of Resident #5's advanced directive. Later that day at 11:19 AM, the CEO confirmed that Resident #5 did not have an advanced directive on file. The report states that this deficiency involved 1 of 5 residents whose records were reviewed.
Failure to Offer Advance Directive Opportunity
Penalty
Summary
The facility failed to ensure residents were offered the opportunity to create an advance directive for Resident #13, who was re-admitted with multiple diagnoses including hypertension, chronic kidney disease, and mild cognitive impairment. Record review on 6/24/26 showed that Resident #13 did not have an advance directive on file. On 6/25/26 at 2:43 PM, the Social Service Director stated there was no documentation that education was provided to Resident #13 and no attempts were made to obtain an advance directive.
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