Failure to Honor Resident Representative’s Authority in Contractor-Mediated Medicaid Application
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
A facility failed to ensure a resident's POA signed the admission paperwork, instead allowing the resident's son-in-law, who was not an authorized representative, to sign. The resident had severe cognitive impairment and multiple medical conditions. The Admission Director confirmed the error, which was identified during a complaint investigation.
A facility failed to ensure a resident with severe cognitive deficits had a legal guardian after the previous guardian was removed. Despite the resident's inability to make decisions, the facility did not have power of attorney documentation or initiate guardianship proceedings, leaving the resident without proper representation.
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.
Failure to Obtain POA Signature on Admission Paperwork
Penalty
Summary
The facility failed to ensure that the Power of Attorney (POA) for a resident signed the admission paperwork, which is a requirement for exercising the resident's rights. The resident, who had severe cognitive impairment and multiple medical conditions including aphasia, Parkinson's disease, and chronic kidney disease, was admitted with the POA designated as the resident's wife. However, the admission paperwork was signed by the resident's son-in-law, who was not an authorized representative or the POA. Interviews revealed that the POA was not given the opportunity to review and sign the admission documents. Instead, the admissions staff approached the resident's room with an iPad, requesting a family signature to complete the paperwork, leading to the son-in-law signing the documents. The Admission Director confirmed that the son-in-law, who was not the POA, signed all necessary admission paperwork, which should have been signed by the POA. This deficiency was identified during the investigation of a complaint.
Failure to Secure Legal Guardian for Resident
Penalty
Summary
The facility failed to ensure that a resident, who no longer had the capacity to make decisions, had a legal guardian in place. The resident, who was admitted with multiple diagnoses including secondary Parkinsonism, diabetes mellitus, aphasia, hyperlipidemia, bipolar disorder, depressive episodes, schizoaffective disorder, anxiety disorder, and dementia, was previously deemed incompetent, and a family member was appointed as the guardian. However, this guardianship was removed in 2017 due to the family member's failure to file necessary reports. Despite this removal, the facility continued to list the family member as the emergency contact and responsible party without any evidence of power of attorney documentation. Interviews with facility staff revealed that there was no financial power of attorney or guardianship in place for the resident, and the county lacked available guardians. The Business Office Manager and Secretaries indicated that a local attorney was providing guardianship services, but the facility had not initiated the process to secure a guardian for the resident. The Administrator was unaware of the local attorney's services and stated that the necessary documents would be sent to begin the guardianship process. This oversight affected the resident's ability to have their rights exercised through a legal representative.
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