F0551

D

Failure to Honor Resident Representative’s Requests and Concerns Regarding Change in Condition

Massillon, Ohio Survey Completed on 01-22-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely address and act upon the concerns and rights of a resident’s representative, despite documentation that this representative held Health Care Power of Attorney (HCPOA). The resident was admitted with multiple serious diagnoses, including cerebral infarction, COPD, chronic bronchitis, acute respiratory failure, atherosclerotic heart disease, hypertension, congestive heart failure, ischemic cardiomyopathy, and vision loss. On admission, the face sheet listed a specific family member as the emergency contact, and HCPOA paperwork dated and notarized on 08/11/25 named this same family member as HCPOA; this paperwork was later submitted to the facility. The resident had a DNR-CC-A order and was documented as having intact cognition on the admission MDS, with later documentation of moderately impaired cognition.

On 09/15/25, the resident’s vital signs were within normal limits, but the resident complained of being more tired than usual. That same day, the family member called the facility stating the resident “must go to the hospital,” reporting that the resident was slurring his speech and not acting right, and that he had not been calling as frequently as usual. The LPN explained to the family that the facility could perform a workup in-house, and the physician was notified and ordered a CBC, CMP, urinalysis, urine culture, and chest x-ray for complaints of shortness of breath. A chest x-ray performed on 09/15/25 showed linear opacities in the left lower zone, pulmonary congestion, and elevation of the left hemidiaphragm, with a recommendation for a follow-up HRCT lung scan. A progress note on 09/16/25 documented these x-ray findings and stated that the family member and physician were aware. However, the physician later reported he was not aware that the family had requested the resident be sent to the hospital because he was acting differently, and stated that this information must not have been communicated to him.

The family member reported having repeatedly requested that the resident be sent to the hospital and stated that the resident himself had expressed a desire to go to the hospital. She also stated she had completed MPOA paperwork at the hospital and had emailed the facility’s Social Worker several times about this paperwork, later finding and sending the HCPOA documents to both Social Services and the DON on 09/17/25. The DON acknowledged that the facility did not initially have the MPOA paperwork and stated she did not feel the resident needed to be sent out on 09/15/25 because his vital signs were stable and she did not know the person on the phone, despite the family member being listed as emergency contact. The DON further stated she assessed the resident but did not document her assessment in the progress notes and could not recall whether she or the LPN had spoken to the physician on 09/15/25. The LPN confirmed that the family member had requested a hospital transfer and that he initially planned to send the resident out but did not, and he could not recall why the plan changed. He also confirmed that he communicates with the physician via his personal cell phone and could not find any record of a call or text to the physician on that date.

Social Service staff reported multiple conversations and email exchanges with the family member about the resident’s condition and the MPOA paperwork, including the family member’s ongoing requests that the resident be sent to the hospital and complaints that the resident said he could not breathe at night and was not receiving aerosol treatments. The Social Service Designee stated she contacted the hospital to obtain MPOA paperwork but never received it with the admission documents, and she did not document her conversations with the family member in the medical record. The DON later confirmed that the resident had PRN albuterol aerosols ordered but none were administered for shortness of breath, and that the resident refused lab work. On 09/21/25, the resident was found with right-sided facial droop, aphasia, and decreased mental status; 911 was activated, and the resident was sent to the hospital for stroke-like symptoms, where he later died. The surveyors concluded that the facility failed to ensure the concerns and requests of the resident’s family representative were addressed timely and that the representative was able to exercise the resident’s rights, affecting one resident reviewed for change in condition.

This deficiency was investigated under Complaint Number 2631680 and was based on record review and multiple staff and family interviews. The findings included lack of timely recognition and response to the family member’s repeated concerns and requests for hospital transfer, incomplete or missing documentation of assessments and communications, failure to promptly verify and act upon HCPOA documentation submitted by the family, and failure to consistently document or communicate the family’s reports of the resident’s change in condition to the physician. The DON and LPN both acknowledged gaps in documentation and uncertainty about who contacted the physician, while the physician stated he was not informed of the family’s concerns about the resident acting differently. These actions and inactions led to the determination that the facility did not ensure the resident’s representative could effectively exercise the resident’s rights.