Failure to Honor Guardian’s Request and Physician Order for PRN Psychotropic Medication Sequence
Summary
The deficiency involves the facility’s failure to honor a court-appointed guardian’s request and a physician’s order regarding the sequence of administering PRN psychotropic medications for a resident with a traumatic brain injury, depression, anxiety, and behavioral disturbances. The guardian, based on her observations, preferred that PRN Ativan be administered first for the resident’s aggressive and yelling behaviors, and only if ineffective, that PRN Trazodone be used, as Trazodone made the resident appear sleepier rather than improving behavior. This preference was communicated to the DON on 02/05/26, documented in a nurse’s progress note, and relayed to the physician, who issued an order specifying that Ativan should be tried first before Trazodone. Facility policies stated that residents or their legal representatives have the right to participate in care planning, that medications must be administered in accordance with prescriber orders, and that psychotropic medication management is an interdisciplinary process involving the resident and representative. Despite the guardian’s request and the explicit physician’s order to try Ativan first, MAR reviews for February and March 2026 showed multiple instances where PRN Trazodone was administered without a prior trial of PRN Ativan, or where Trazodone was given earlier in the day and Ativan only later, contrary to the ordered sequence. Specific dates documented repeated administration of Trazodone alone or before Ativan. In interviews, two nurses acknowledged they were aware of the guardian’s request and the order to use Ativan first, yet they administered Trazodone prior to Ativan, with one nurse stating she believed Trazodone was more effective. The DON confirmed that the expectation was for all nurses to follow physician orders, including directions, but the documented medication administration patterns and staff interviews demonstrated that the order and the guardian’s expressed preferences were not consistently followed.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia and severe cognitive impairment had an insurance disenrollment form completed and signed by the resident instead of the resident’s DPOA/representative, even though the facility had previously recognized the spouse as the decision-maker. The family later reported the insurance was changed without their knowledge or permission, and the BOM confirmed the form was completed without involvement of the responsible party.
Failure to Notify POA of Resident Changes in Condition: A resident with metabolic encephalopathy, endometrial cancer, and HTN had multiple COCs documented, and the record showed the resident was informed, but there was no documentation that the designated health care POA was notified. RN confirmed staff failed to notify the POA, leaving the representative unaware of the resident’s condition changes.
Failure to establish a responsible party for a resident with severe cognitive impairment and inability to make medical decisions. The resident had metabolic encephalopathy, schizophrenia, and heart failure, and the record listed family emergency contacts, but the SSD and DON stated the family should have been contacted to serve as the resident’s RP for medication consent and other medical decisions.
Failure to Provide Resident Representative for Incapacitated Resident: A resident who lacked capacity to make medical decisions was not provided a resident representative or public patient representative through OLTCPR. Records showed the IDT was listed as the legal decisionmaker, transfer documentation listed only the IDT, and multiple care conference records did not show representative participation. The SSD confirmed the facility did not involve a resident representative and did not contact OLTCPR, and the DON acknowledged the resident needed a representative for overall care.
Unauthorized Family Member Signed Medical Consents: A resident with an activated POAHC and moderately impaired cognition had multiple medical consent documents and DNR paperwork signed by a family member who was not the designated POAHC. Interviews confirmed the family member was not the named healthcare decision maker, and the facility did not have the correct contact information for the resident’s primary POAHC.
Delayed Identification of Authorized Health Care Decision Makers: Two residents with dementia were identified as lacking decision-making capacity at admission, but their records did not clearly identify who was authorized to make health care decisions. The chart listed family contacts, and surrogate decision maker affidavits were not completed until nearly two years after admission.
Resident Representative Not Involved in Insurance Change
Penalty
Summary
The facility failed to ensure that the resident representative’s rights were exercised for one resident with dementia and cognitive communication deficit. The resident was admitted on 1/26/26, and the admission agreement was signed by the resident’s durable power of attorney, who had served in that role since June 2010. A progress note on the day of admission documented that code status was confirmed with the spouse/representative, and the admission MDS later documented severe cognitive impairment. Despite this, on 2/26/26 a disenrollment form changing the resident’s insurance coverage was completed by the BOM and signed by the resident rather than the resident’s representative. A social services note later documented that the family expressed concern about the insurance being converted and upset about the change. During interviews, the representative stated the change was made without knowledge or permission and that the facility did not discuss it beforehand, and the BOM confirmed the disenrollment form was completed without involvement of the responsible party.
Failure to Notify POA of Resident Changes in Condition
Penalty
Summary
The facility failed to notify the resident’s Power of Attorney for health care decisions during multiple changes of condition for one resident. The resident had diagnoses including metabolic encephalopathy, malignant neoplasm of the endometrium, and hypertension, and the admission record showed the resident had a POA. The Advance Health Care Directive named FM1 as the designated agent for health care decisions. The resident’s MDS indicated the resident had clear speech, some difficulty communicating words or finishing thoughts, and depended on staff for personal hygiene, toileting hygiene, and showering/bathing. Review of the resident’s change-of-condition documentation and progress notes showed several changes of condition and that the resident was made aware of them, but there was no documentation that the health care decision maker was notified. During interview, RN1 stated staff failed to notify FM1 of all of the resident’s changes in condition, leaving FM1 unaware and uninformed of those changes. The facility policy on change-of-condition notification stated the facility should promptly inform the resident and notify the resident’s legal representative when the resident experiences a change in condition.
Failure to Establish a Responsible Party for a Cognitively Impaired Resident
Penalty
Summary
The facility failed to determine the responsible party for Resident 9, a resident with metabolic encephalopathy, schizophrenia, and heart failure whose cognition was severely impaired and who was dependent on staff for oral hygiene, toileting, bathing, upper and lower body dressing, and putting on and taking off footwear. The resident’s admission record listed two family members as emergency contacts, and the History and Physical stated that the resident could make needs known but could not make medical decisions. During interview, the Social Services Director stated that because Resident 9 was unable to make medical decisions, the resident’s sister and son should have been contacted to see if one of them wanted to serve as the resident’s responsible party. The Director of Nursing also stated that Resident 9 required a responsible party to consent for medications and make other medical decisions. The facility policy stated that when a resident is declared incompetent or incapable of understanding rights, the resident’s surrogate and/or representative is to be advised of the resident’s rights and responsibilities.
Failure to Provide Resident Representative for Incapacitated Resident
Penalty
Summary
The facility failed to ensure Resident 6, who was unable to make her own decisions, was provided with a resident representative or a public resident representative through the Office of the Long-Term Care Patient Representative as required by AFL 23-18. Review of the resident’s H&P showed she had no capacity to understand and make decisions, and her Notification and Decision Making for Incapacitated Resident form showed she was informed of the right to have a resident representative participate in the IDT decision-making process and the right to judicial review of IDT decisions. Her POLST listed the facility’s IDT as her legal decisionmaker. Record review showed the Resident Representative Notified section of the SNF/NF to Hospital Transfer Form listed only the IDT, and the document did not show that the resident’s representative or a public resident representative from the OLTCPR was notified of the hospital transfer. Multiple Interdisciplinary Care Conference documents for care conference and psychotropic medication management failed to show documented evidence that a resident representative participated in the meetings. During interviews, the SSD verified the facility did not involve a resident representative in Resident 6’s care as required by AFL 23-18 and stated she did not contact the OLTCPR to obtain a public resident representative. The DON confirmed Resident 6 could not make her own medical decisions and stated a resident representative should have been present for her overall care.
Unauthorized Family Member Signed Medical Consents
Penalty
Summary
The facility did not ensure the resident’s representative was able to exercise the resident’s healthcare rights for 1 resident with an activated Power of Attorney for Healthcare (POAHC). The resident’s record showed a POAHC document naming POAHC-C as the primary decision maker, and the resident had a BIMS score of 10 out of 15, indicating moderately impaired cognition. Despite this, the record contained multiple documents signed by Family Member-D, who was not the designated POAHC and had no documented authorization or declination from POAHC-C, including consent and authorization to treat, consents for bupropion, trazodone, fluoxetine, and Lamictal, and DNR paperwork. During interviews, Social Services stated Family Member-D told the facility they were the primary POAHC, but the document identified POAHC-C as the POAHC; the resident stated POAHC-C was their primary medical decision maker, and the NHA stated the facility did not have the correct contact information for the resident’s primary POAHC.
Delayed Identification of Authorized Health Care Decision Makers
Penalty
Summary
Facility staff failed to timely identify a surrogate decision maker authorized to exercise the rights of residents who lacked decision-making capacity. Resident #114 was admitted in June 2024 with multiple diagnoses including dementia and was identified at admission as lacking decision-making capacity, but the record only identified the resident's children as points of contact and did not indicate who was responsible for making health care decisions. Resident #13 was admitted in February 2024 with multiple diagnoses including dementia and was also identified at admission as lacking decision-making capacity, but the record listed the resident's child and two other family members as points of contact without identifying who was authorized to make health care decisions. During the survey, the Director of Social Services stated that advance directives are reviewed with the resident or representative upon admission and that, for residents lacking decision-making capacity, the family is contacted to determine whether an advance directive exists. If none is in place, the family is informed that a surrogate decision maker affidavit must be completed. The surveyor informed the Director of Social Services that the records for Resident #13 and Resident #114 did not clearly identify the family member authorized to make health care decisions, and later received surrogate decision maker affidavits showing that Resident #13's family member signed in March 2026 and Resident #114's family member signed in May 2026, nearly two years after each resident was admitted.
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