Failure to Honor Resident’s POA Request for Medical Records
Summary
The facility failed to allow a resident’s designated representative, who held power of attorney (POA), to exercise the resident’s rights by obtaining the resident’s medical records. The resident had impaired cognitive function with a BIMS score of 5 and had formally designated a family member as POA effective 12/24/24, with authority over long‑term placement, health care, mental health including medications, and hospitalizations. According to the state agency complaint intake, the POA was concerned about the care the resident was receiving and requested the resident’s medical records before the resident passed away, but the facility never provided them. A nursing progress note documented that the POA approached the ADON and staff, stating she was still waiting on medical records and needed to sign whatever was required to obtain them, and expressed that the delay was unacceptable. Interviews and record review showed that the facility’s process for releasing records created a barrier for the POA, despite staff acknowledging her authority and the resident’s lack of capacity to request records independently. LPN #1 stated that family members requesting medical records had to go to Medical Records (MR). The MR staff confirmed that the POA requested the records and was given paperwork to complete on two occasions; the first form was filled out incorrectly, and the POA was told to redo it. MR reported that the corrected paperwork was not returned until after the resident died, at which point the facility required additional paperwork to release records after death. MR also acknowledged knowing that the POA could act on the resident’s behalf and that, unlike a resident’s oral request, the POA was required to complete written forms. As a result, the POA never obtained the resident’s medical records.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with moderate cognitive impairment and established healthcare and financial POA was referred by the facility to a contracted Medicaid application assistance company without documenting the POA on the face sheet or obtaining the POA’s consent. The contractor met with the resident alone, obtained the resident’s signature on Medicaid-related documents, and collected detailed financial and employment information, even after the POA identified themselves by phone and stated the resident should not sign paperwork and that documents should be left for POA review. The facility could not provide any signed consent from the POA authorizing the contractor’s involvement, resulting in the POA’s decisions not being treated with the same authority as the resident’s own decisions.
Failure to Honor Resident Preference for Body Pillow: A resident with cognitive impairment, ADL dependence, and high fall risk had a spouse-requested body pillow used as part of bed positioning and fall prevention. Staff and records showed the pillow was tied to the spouse's preference, but it was not consistently honored, and an LPN confirmed the preference was not followed. The spouse and the Administrator/DON acknowledged the issue.
A resident with multiple serious cardiac and pulmonary conditions experienced changes in behavior and speech that prompted the designated family representative, who held HCPOA, to repeatedly request hospital transfer and report concerns such as slurred speech, reduced contact, and complaints of shortness of breath. An LPN and the DON opted to perform an in-house workup with labs, urinalysis, and chest x-ray instead of sending the resident to the hospital, and the DON cited stable vital signs and lack of MPOA paperwork on file as reasons not to transfer, despite the family member being listed as emergency contact and later submitting HCPOA documents. The chest x-ray showed pulmonary congestion and other abnormalities, but the physician later stated he was not informed that the family had requested hospital transfer due to the resident acting differently. Social Services and nursing staff acknowledged multiple communications with the family member about the resident’s condition and the MPOA paperwork, but these interactions and the DON’s assessment were not documented in the medical record. Several days later, the resident developed acute stroke-like symptoms and was sent to the hospital, where death occurred, and surveyors found that the facility failed to ensure the resident’s representative could effectively exercise the resident’s rights and that concerns were addressed in a timely manner.
A resident with severe cognitive impairment and multiple serious medical conditions was admitted with Aetna Managed Medicare as the primary payer. The admission paperwork designated the facility’s business office manager as an authorized representative for Medicaid matters, but the required signatures were incomplete, rendering the form ineffective. Subsequently, the resident’s insurance payer was changed first to Medicare A and then to private pay, resulting in daily coinsurance charges and a substantial bill, without any documented discussion or consent from the resident’s POA. The POA and family reported they did not authorize or even know about the insurance changes, while facility billing staff confirmed the charges and billing but denied knowing who changed the payer source.
A resident with co-guardians appointed for personal decisions was allowed to sign consent and declination forms for influenza and COVID-19 immunizations, rather than having the co-guardians provide consent as required. The DON was unsure of the proper consent process and had the resident sign the forms, with no documentation of guardian involvement.
A resident with multiple medical and psychiatric diagnoses, who was assessed as cognitively intact, had his preference for sponge baths and right to refuse showers disregarded when staff contacted his POA to obtain permission to proceed with a shower against his wishes. Despite the resident's ability to make his own care decisions, staff deferred to the POA and completed the shower, failing to honor the resident's rights.
Failure to Honor Resident Representative’s Authority in Contractor-Mediated Medicaid Application
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s appointed power of attorney (POA) was allowed to exercise the resident’s rights and have their decisions treated as if made by the resident. The resident had diagnoses including cognitive communication deficit, history of transient ischemic attack and cerebral infarction, and end stage renal disease, and a BIMS score indicating moderate cognitive impairment. The resident had both a healthcare and financial POA in place, effective prior to the events, and the admission agreement was signed by the POA rather than the resident. However, the resident’s face sheet dated 03/12/26 did not list a POA, and this incomplete information was provided to a contracted Medicaid application assistance company. The facility’s Float Business Office Manager confirmed that the facility had an active contract with the Medicaid assistance contractor and that the facility referred the resident to this contractor, providing the resident’s face sheet without POA information. The contractor’s representative met with the resident alone on 03/19/26 without the POA present and without prior notification to or consent from the POA. During this meeting, the contractor had the resident sign paperwork related to Medicaid application processing, despite the POA having informed the contractor by phone that they were the resident’s POA, that the resident should not be signing paperwork independently, and that documents should be left for review by the POA and the resident. The resident reported significant memory issues, inconsistent recall, and missing details, and stated she communicated these limitations to the contractor multiple times, telling him she could not sign the paperwork herself and that her POA needed to review and sign it. Despite this, the resident signed documents she did not understand, while the contractor asked detailed questions about her work history and life insurance and continued to probe for additional information. The POA later learned that the contractor had contacted the resident’s bank and previous employers seeking financial and employment information, and the resident expressed feeling unhappy and uneasy that the contractor had her personal information without her knowledge. The facility was unable to provide documentation of any signed consent by the POA authorizing the contractor to work with the resident, demonstrating that the POA’s authority and decisions were not given the same consideration as if made by the resident.
Failure to Honor Resident Preference for Body Pillow
Penalty
Summary
The facility failed to honor Resident #51's spouse's preferences regarding the resident's body pillow. Resident #51 was admitted with diagnoses including COPD, cerebral infarction, muscle weakness, and difficulty walking. The record showed he had a BIMS score of 7, was dependent on staff for ADLs, and was assessed as high risk for falls and at risk for wandering. Physician orders included fall prevention measures, including a perimeter mattress and floor mat, and the care plan identified decreased ability to perform ADLs with interventions for bed positioning, mobility, transfers, and the need for a bolstered mattress with a mat on the floor. Documentation and observations showed the body pillow was part of the spouse's preference and was intended to help keep Resident #51 from rolling out of bed. A progress note and concern log reflected that the Administrator was replacing the missing body pillow and that the spouse had raised concern about it. During observation, the resident's recliner had a sign stating no pillows, blankets, or sheets on the chair, while three regular pillows and one body pillow were piled on the recliner. An LPN stated the body pillow should be placed in the bed and tucked under the sheet around the perimeter to stop the resident from falling out of bed, and confirmed the spouse's preferences were not honored. The spouse stated the facility rarely honored her preferences regarding the resident's care, and the Administrator and DON confirmed they were aware of the spouse's preference for the body pillow and had replaced it in the past.
Failure to Honor Resident Representative’s Requests and Concerns Regarding Change in Condition
Penalty
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.
Failure to Honor POA Authority Over Resident’s Insurance and Financial Affairs
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s power of attorney (POA) right to manage the resident’s financial affairs, specifically the right to select and control the resident’s insurance payer source. The resident was admitted with severe cognitive impairment, was dependent on staff for all ADLs, and had multiple serious medical diagnoses including nontraumatic intracerebral hemorrhage, metabolic encephalopathy, acute respiratory failure, hemiplegia, severe protein malnutrition, and a tracheostomy. At admission, the primary payer source was Aetna Managed Medicare. The admission agreement’s Designation of Authorized Representative page for the Ohio Department of Medicaid listed the facility’s Business Office Manager as the representative, but the form only contained a hand-printed initial and last name of the resident’s POA in the signature box of the person granting authority, with no signature from the authorized representative. The form itself stated it had no effect unless signed by both parties. On a later date, the primary payer source was changed from Aetna Managed Medicare to Medicare A, and then subsequently to private pay, without any documented evidence that the facility discussed these changes with the resident’s POA. An invoice dated shortly after the payer change showed the resident was billed coinsurance of $209 per day for a specified period, totaling $4,399.50, with a due date the following month. The resident’s family member and POA reported they did not authorize any insurance changes and were not asked for permission to change the insurance payer source, and they believed the Business Office Manager had made the change without consent. Facility staff, including the Accounts Receivable Supervisor and Business Office Manager, confirmed the resident had been charged $209 per day due to the payer change and that a bill had been issued, but they denied making or knowing who made the change. The POA stated that, due to the disenrollment, the resident accrued expenses from the facility and other providers, and that the facility had not sought her permission to alter the insurance payer source.
Failure to Obtain Guardian Consent for Immunizations
Penalty
Summary
The facility failed to ensure that a resident's co-guardians were permitted to exercise their authority to consent or decline influenza and COVID-19 immunizations. The resident, who had diagnoses including ataxic cerebral palsy, epilepsy, nutritional anemia, schizophrenia, and obsessive-compulsive disorder, was admitted with co-guardians appointed for personal decisions. The medical record listed the co-guardians as primary contacts, and official court documents confirmed their status as co-guardians of the person. Despite this, the care plan did not specifically reference the guardians, instead using the term 'resident representative.' Consent forms for both COVID-19 and influenza vaccinations were signed by the resident, who was assessed as cognitively intact, rather than by the co-guardians. The Director of Nursing (DON) acknowledged uncertainty regarding the consent process and had the resident sign the forms, although she stated she contacted the guardian by phone, which was not documented in the record. This resulted in the co-guardians not being given the opportunity to exercise their legal authority to consent or decline immunizations for the resident.
Failure to Honor Resident's Right to Refuse Care
Penalty
Summary
The facility failed to honor a resident's right to make choices regarding personal care, specifically related to bathing preferences. The resident, who had chronic kidney disorder, bipolar disorder, major depressive disorder, generalized muscle weakness, and required assistance with activities of daily living, was assessed as cognitively intact and able to make his own decisions. The care plan indicated that staff should assist with bathing according to the resident's preferences, and a preference evaluation showed the resident preferred sponge baths and valued having his brother involved in care discussions. Despite this, nursing documentation revealed that when the resident refused a shower, staff contacted his Power of Attorney (POA) to obtain permission to proceed with the shower against the resident's wishes, citing concerns about soiled linens and hygiene. The POA ultimately gave permission for the shower, and staff proceeded to bathe the resident. Further review and interviews confirmed that the resident had not been deemed incompetent and did not have a guardianship assigned, meaning his right to make decisions about his care remained intact. The Administrator and DON acknowledged that the POA's authority did not override the resident's choices as long as he was capable of making his own decisions. The incident demonstrates that the facility did not respect the resident's expressed preferences and right to refuse care, as required by regulations, and instead deferred to the POA despite the resident's cognitive ability to make his own choices.
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