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
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RP Not Notified Before Podiatry Service: A resident with Alzheimer’s disease, DM, PVD, and no decision-making capacity had a podiatry visit for toenail trimming even though the RP/POA had a documented request that no ancillary consults occur without prior notice and approval. The RP stated she had repeatedly told staff she needed to be informed first, but the podiatrist trimmed the resident’s toenails before she was notified. The SSA, ADON, DON, and an LVN all confirmed the RP was not informed before the service and that the resident’s right to have the RP notified was not followed.
A resident with schizoaffective disorder, bipolar type, reported an alleged assault by another resident, and police were notified. An LPN notified the guardian using the office number instead of the required after-hours emergency number listed in the chart and agreed-upon protocol for significant changes in condition and law enforcement contact; the DON confirmed the wrong number was used.
Failure to identify a responsible party for a resident without decision-making capacity. A resident with hemiplegia, hemiparesis, and aphasia was documented as severely cognitively impaired and unable to understand or make decisions, yet the Face Sheet listed the resident as self-responsible. The SSD stated the listed EC could not be reached, other contacts were also unreachable, and no RP was established to make medical decisions on the resident’s behalf.
Failure to Honor DPOA Authority for Resident Leave-Outs: A resident with dementia, psychosis, aphasia, severe cognitive impairment, and elopement risk was documented as only being allowed out of the facility by the DPOA, yet a family member who was not authorized removed the resident from the building. The sign-out process, second authorization book, care plan, and nursing documentation did not reflect the restriction, and facility leaders confirmed the resident had been taken out without DPOA authorization on more than one occasion.
Resident Lacked Proper Representation for Decision-Making: A resident with dementia, severe cognitive impairment, and inability to speak or make needs known did not have a guardian or POA. Staff confirmed family members listed as emergency contacts were not documented decision-makers, and the Administrator, DON, and SW all acknowledged the resident needed formal representation to advocate for medical and personal needs.
Failure to Honor AHCD and Legal Representative Rights: A resident with COPD and intact cognition had an AHCD naming his son as the health care decision maker effective immediately, but the facility did not verify or implement the document. The LR said he signed consents but was not notified of care conferences, discharge planning, or changes in condition. The DSS said the DPOA was not activated because the resident could make his own decisions, yet she had not reviewed the AHCD, and there was no documented IDT review of the directive.
RP Not Notified Before Podiatry Service
Penalty
Summary
The facility failed to follow the Responsible Party’s request to be notified before any ancillary services were provided to a resident who lacked decision-making capacity. Resident 1 was admitted with diagnoses including unspecified Alzheimer’s disease, diabetes mellitus, and unspecified peripheral vascular disease. The admission record identified the RP as having POA, and the physician order dated 10/29/2025 stated that no ancillary consults were to be performed without prior notice and approval from the RP. The resident’s H&P dated 4/19/2026 stated the resident did not have the capacity to understand and make decisions, and the MDS dated 4/30/2026 indicated severely impaired cognitive skills for daily decisions and dependence on staff for all ADLs. Despite this documented restriction, the podiatrist trimmed the resident’s toenails on 5/18/2026. The podiatry notes documented debridement and trimming of toenails using a nail clipper and Dreme. During interview, the RP stated she had previously told staff in multiple IDT meetings that she had to be informed first before the resident could be seen by outside services such as podiatry. The RP later noticed that someone had cut the resident’s toenails and stated she had not been notified before the podiatry visit. Facility staff confirmed the RP was not notified before the podiatrist came. The SSA stated she was covering for another SSA, was not familiar with the resident, and did not notice the RP’s request that no ancillary services occur unless she was informed and agreed. The SSA stated the nurse had requested podiatry for long toenails, the referral was emailed, and the podiatrist trimmed the toenails before the RP was notified. The ADON, DON, and LVN 1 all stated the RP’s right to be informed prior to the procedure was not followed, and the DON stated the resident had no capacity to decide for herself and that the RP should have been informed before the podiatrist visit.
Failure to Use Correct Guardian Notification Protocol
Penalty
Summary
The facility failed to notify Guardian A using the agreed-upon after-hours protocol for a resident with schizoaffective disorder, bipolar type, when the resident experienced a change in condition. The resident’s record listed Guardian A’s emergency after-hours phone number, and the Public Administrator Emergency Call Information form specified that the on-call number was to be used for significant changes in the ward’s condition and for contact with law enforcement. After the resident reported that another resident grabbed the resident by the arm and said the resident would rape them, LPN A notified Guardian A using the guardian’s office number instead of the emergency after-hours number. The record also showed that police were notified of the alleged incident and that the resident spoke with police about it. During interviews, Guardian A confirmed the office number called was not the correct number and stated the facility had signed a form in 2025 acknowledging the correct after-hours notification protocol. LPN A said the number called was the one on the resident’s face sheet and did not see the after-hours number there, while LPN B and the DON stated staff were expected to use the after-hours emergency number and speak with someone when notifying the guardian of a change in condition. The DON stated LPN A had not followed the facility’s protocol.
Failure to Identify a Responsible Party for a Resident Without Decision-Making Capacity
Penalty
Summary
The facility failed to identify and determine a responsible party for Resident 63, a resident with hemiplegia and hemiparesis following cerebral infarction and aphasia. The resident’s Face Sheet listed the resident as self-responsible and identified three family members as emergency contacts, along with two additional family members without a contact type. However, the resident’s MDS dated 3/5/2026 indicated severely impaired cognitive skills for daily decision making and dependence on staff for multiple activities of daily living, and the H&P dated 8/29/2025 stated the resident did not have the capacity to understand and make decisions. During interview, the SSD stated Resident 63 was aphasic, could not understand the plan of care, and could not make medical decisions, and that communication regarding the resident’s health was supposed to be with Emergency Contact 1. The SSD also stated she had been unable to reach Emergency Contact 1 for the last two care conferences, had attempted to call the other listed emergency contacts without success, and did not contact the two additional family members because no contact type was listed for them. The SSD stated she should have realized the resident had no RP because Emergency Contact 1’s phone number was not valid. The DON stated that having a designated RP for residents without decision-making capabilities was important for communication and for making critical decisions if an emergency or change in condition occurred. The facility policy stated that if a resident was determined to be incompetent, the resident’s rights would be exercised by the resident representative on the resident’s behalf.
Failure to Honor DPOA Authority for Resident Leave-Outs
Penalty
Summary
The facility failed to ensure the resident representative’s authority was followed when a family member who was not the resident’s DPOA took the resident out of the facility. Resident #3 had diagnoses including dementia, psychosis, altered mental status, and aphasia, was documented as an elopement risk, was deemed incapacitated, and had special instructions stating the resident could only be taken out of the facility by the DPOA, who was the resident’s granddaughter. The resident’s care plan identified impaired cognition, disorientation, wandering, and a history of attempts to leave unattended, but it did not address obtaining permission from the DPOA before relatives took the resident out. The resident’s DPOA reported that the facility released the resident to a family member without authorization and stated this was not an isolated incident, identifying prior occasions when the resident was removed from the facility by a relative without DPOA authorization. The sign-out sheet showed a family member signed the resident out and back in on the day of the event. The resident’s Brief Interview for Mental Status showed a score of 4, indicating severe cognitive impairment, and the DPOA report described the resident as a vulnerable adult with dementia and a documented history of wandering who required a secure supervised environment at all times. During interviews, the receptionist stated residents leaving the facility were supposed to sign out and that a second book identified who could take the resident out, but the family member who removed the resident was not on that list. The BOM, ADON, SW, and DON each stated the resident’s care plan should have reflected that only the DPOA could take the resident out, that staff should have checked authorization before release, and that nursing documentation should have been completed when the resident left the unit. They also stated there was no documentation in the nurses’ notes for either time the resident left with a family member.
Resident Lacked Proper Representation for Decision-Making
Penalty
Summary
The facility failed to ensure that one resident with severe communication and cognitive limitations had sufficient representation to advocate for their needs. The resident was admitted on 11/18/24 and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, depression, dementia, atherosclerotic heart disease, tachycardia, and bipolar disorder. A CNA stated the resident understood when spoken to and followed commands but could not respond verbally, and a surveyor’s attempt to communicate through a language line resulted in no verbal response from the resident. A psychosocial progress note documented that the resident was alert and oriented x1, had frequent confusion and forgetfulness, a communication deficit, limited comprehension, and a BIMS score of 00/15 indicating severe cognitive impairment. Interviews with facility staff showed that the resident did not have a guardian or POA. The Administrator stated the facility did not have a policy regarding guardianship or POA and acknowledged the resident was not verbal or able to make needs known and should have a POA or guardian. The DON stated the resident had family listed on the face sheet who could advocate as emergency contacts, but there was no guardian. The Social Worker stated the resident had no POA or guardian, that emergency contacts did not have authority to make decisions, and that a resident who is non-verbal and cannot make needs known requires a POA or guardian. The Administrator stated paperwork was being started for state guardianship, and staff confirmed the resident had been unable to make needs known for at least a year.
Failure to Honor Advance Health Care Directive
Penalty
Summary
The facility failed to ensure the resident’s legal representative had the right to exercise the resident’s rights when the resident’s Advance Health Care Directive was not verified and implemented. The resident was admitted with diagnoses including COPD, and his MDS dated 3/14/26 showed a BIMS score of 15, indicating intact cognition. His Advance Health Care Directive, dated 5/31/22, stated that his son was to have authority to make health care decisions immediately, but the facility did not verify or act on that document after receiving it on 4/9/26. During telephone interviews, the legal representative stated he had a DPOA, signed consent forms for the resident after admission, but was not notified of care conferences, discharge planning, or changes in condition, and said there was miscommunication with the facility. The DSS stated the DPOA would not be activated because the resident’s cognition was intact, but also admitted she did not review the AHCD and was unaware that the son’s authority was effective immediately. The DON confirmed the legal representative did not come to the facility after the documents were signed, and there was no documented evidence that the IDT reviewed the AHCD showing the son as the health care decision maker. The facility policy stated advance directives are honored in accordance with state law and that the interdisciplinary team assesses decision-making capacity and identifies the primary decision-maker.
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