Failure to Use Correct Guardian Notification Protocol
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Provide Medical Records to Legal Surrogate: The facility did not ensure that a resident’s POA was given access to requested medical records for one resident. The resident had neurogenic bladder, anemia, and a hx of stroke. The request was received, incomplete records were sent, and repeated follow-up attempts by phone, voicemail, and a HIPAA Violation Notice did not result in the records being released; facility leadership confirmed legal approval had been obtained but the records still were not provided.
Failure to honor a resident’s requested change to his MPOA. A resident with dementia, stroke, and impaired cognition stated during a care plan meeting that he wanted Family Member A and Family Member C to serve as his MPOA, with Family Member A as primary. The DON, Administrator, and family members confirmed the resident’s stated wishes, but the facility did not update or file the new paperwork, and the Social Worker said she was unaware a new MPOA needed to be completed.
A resident’s clinical record was not updated to reflect the POA’s written authorization allowing the resident’s son to receive healthcare information. The record review found the note only after the fact, and the ED stated she was unaware of it because she was not employed there when it was provided.
Failure to Honor Guardian Advocate Communication Rights: A resident with multiple chronic conditions, including MRSA, stage 3 pressure ulcers, and spina bifida, had a Guardian Advocate authorized to consent to medical treatment, but the facility did not document notifying the representative about repeated refusals of wound care, meds, assessments, labs, or behavioral changes. The family member reported repeated unanswered requests for updates, no informed consents for psychotropic meds, and that she had to personally intervene when the resident became lethargic and not at baseline.
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.
The facility failed to consistently identify and notify the correct RP or guardian and did not document informed consent for care plan changes for several residents. One resident with intermittent confusion had bed rails applied without RP consent, another had the wrong RP listed and contacted for care planning, and two residents who lacked decision-making capacity had no documented health care guardian in the record. Interviews with SW and the DON confirmed the missing or incorrect representative and guardian documentation.
Failure to Provide Medical Records to Resident’s Legal Surrogate
Penalty
Summary
The facility failed to ensure that a resident’s legal surrogate, the power of attorney, was provided access to medical records for one of two residents. Resident R51 was admitted to the facility with diagnoses that included neurogenic bladder, anemia, and a history of stroke. Review of information submitted to the state survey agency showed that a request for patient health information was submitted on 12/19/25, and the custodian was contacted on 12/31/25 after the request was received. The custodian submitted incomplete records on 01/04/26, and from 01/21/26 through 05/26/26, multiple attempts were made to contact the custodian by phone calls, voicemails, and a HIPAA Violation Notice. Despite these efforts, the requested records remained outstanding, and the facility had not released the records without valid justification for the delay. Review of the resident’s electronic medical record did not reveal information related to the request, and facility interviews confirmed that the request had been received by a previous NHA, that legal department approval for release had been obtained, and that the medical records still had not been provided to the requestor.
Failure to Honor Resident’s Requested Medical Power of Attorney Change
Penalty
Summary
The facility failed to ensure a resident had the right to exercise his rights and be treated with respect and dignity when it did not honor his request to change his Medical Power of Attorney after a care plan meeting. Resident #1 was an older male with diagnoses including dementia, stroke, and high blood pressure. His quarterly MDS indicated he was usually understood at times, sometimes understood by others, had a BIMS score of 09, and required assistance with ADLs. His care plan documented impaired cognition and risk for further decline related to dementia, with staff to monitor and report changes in decision-making ability, memory, recall, general awareness, ability to express self, ability to understand others, level of consciousness, and mental status changes. Record review showed Resident #1’s Medical Power of Attorney dated 05/27/26 listed Family Member A as primary and Family Member B as secondary. During the care plan meeting on 06/04/26, the DON, Administrator, Family Member C, and Family Member D stated that Resident #1 said he wanted Family Member A and Family Member C to be his Medical Power of Attorney, with Family Member A as primary. The DON said the resident answered promptly and without hesitation and that she did not feel he was coerced. Family Member C and Family Member D both stated the resident expressed this wish, but the facility had not updated or provided a copy of the new paperwork. The DON said the Social Worker was responsible for completing the paperwork, while the Social Worker said she was unaware she needed to complete a new Medical Power of Attorney and acknowledged that not completing it could be against the resident’s rights and wishes. The Administrator also stated that failure to have the paperwork completed and in the medical record was not honoring the resident’s wishes.
Clinical Record Not Updated for Authorized Family Access
Penalty
Summary
The facility failed to ensure Resident C’s clinical record was updated to reflect the resident’s Power of Attorney’s request that the resident’s son be allowed to receive healthcare information. Resident C’s record was reviewed and showed diagnoses including COPD, diabetes, and depression. The Executive Director later provided a handwritten note dated 9/17/25 stating that Resident C’s son was allowed to receive healthcare information, and the note was signed by the resident’s POA. During interview, the POA stated she had given the previous Executive Director the handwritten note in September 2025 granting permission for the son to receive healthcare information. Despite this, the clinical record lacked documentation authorizing the son to receive healthcare information, and the Executive Director stated she was unaware of the handwritten note because she was not employed there when it was provided.
Failure to Honor Guardian Advocate Communication Rights
Penalty
Summary
The facility failed to ensure the rights of a resident representative, appointed as Guardian Advocate and authorized to consent to medical treatment, were honored in relation to communication about the resident’s health status. The resident’s family member reported that she had been appointed Guardian Advocate in October 2025 and had provided the paperwork to the Admissions Director at admission, but she repeatedly contacted the facility for updates and did not receive return calls. She also stated she had not signed any informed consents for psychotropic medications and that, after visiting the facility and finding the resident lethargic and not at baseline, she requested transfer to the hospital, after which the resident received care. The resident was admitted on 04/23/2026 and later discharged. The clinical record identified the same family member as Emergency Contact and Guardian, and the guardianship paperwork appointing her as Guardian Advocate with authority to consent to medical treatment was scanned into the record on admission. The resident had diagnoses including malfunction of a continent urinary stoma, muscle weakness, MRSA infection, neuromuscular bladder dysfunction, fibromyalgia, chronic pain syndrome, stage 3 pressure ulcers, and spina bifida. The care plan contained no advance directive care plan. Nursing progress notes documented repeated refusals of wound care, medications, assessments, vital signs, labs, and evaluations, along with behavioral episodes such as screaming, combativeness, and refusal of care on multiple dates, but there was no documentation that the Guardian Advocate was notified of these refusals, behavioral changes, or other concerns. The NHA stated he reviewed the guardian paperwork at admission but believed the facility needed a determination of incapacity and had not contacted legal for guidance.
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 Involve Correct Representatives in Care Decisions
Penalty
Summary
The facility failed to identify and notify residents’ health care representatives or guardians of changes to the plan of care and failed to involve them in the consent process for several residents. During the annual survey, this was identified for 4 of 76 residents reviewed for resident rights and representative involvement. The findings involved residents with confusion, lack of decision-making capacity, or unclear representative documentation, and the record reviews and interviews showed that the facility did not consistently document or verify the correct responsible party or guardian. For one resident, staff assessed the need for bed rails, documented that bilateral grab bars were indicated, and initiated a care plan intervention to educate the resident and resident representative about the risks and benefits of bed rails, including entrapment. The resident was intermittently confused, and a social work note stated the listed RP could not be contacted because the number was invalid. The facility policy required informing the resident or representative about the benefits and hazards of bed rails and obtaining informed consent before use, and the acting DON confirmed that the resident’s RP did not give consent before the bed rails were applied. For another resident, the medical record listed the wrong RP, and staff contacted that incorrect person regarding care plan meetings and change-in-condition notifications. A social worker confirmed the listed name and number were not the actual RP and stated the spouse was the RP and had been involved in the plan of care, but there was no reference to the spouse’s name or number in the record. Two additional residents lacked evidence of an appointed health care guardian despite documentation that they had no decision-making capacity; one resident had diagnoses including cognitive communication deficit and intellectual disabilities, and the other had been certified by the physician as lacking decision-making capacity shortly after admission. Social work interviews confirmed that the facility did not have guardianship documentation and that the records did not show evidence of staff helping obtain a health care guardian.
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