Failure to Honor Legal Guardian’s Medication Decisions and Obtain Valid Psychotropic Consents
Summary
The deficiency involves the facility’s failure to honor a legal guardian’s right to make medication treatment decisions for a resident who was severely cognitively impaired and unable to make his own decisions. The resident was admitted with multiple diagnoses including legal blindness, heart failure, dysphagia, alcohol abuse, and kidney disease, and had a BIMS score of 6/15 indicating severe cognitive impairment. Guardianship paperwork identified two family members as co‑guardians. Despite this, the resident was started on quetiapine 50 mg twice daily via tube for behavior following hospital discharge, based on a hospital discharge summary that noted quetiapine had been started for agitation with good response. A medication informed consent form for quetiapine dated shortly after admission documented verbal consent “on the phone” without listing any name under resident/legal representative, left the reason for the prescription blank, and was signed only by a facility representative. The facility also obtained and implemented orders for clonazepam without clearly documented, valid consent from the co‑guardians and in conflict with one guardian’s stated wishes. A medication informed consent form dated several days after admission documented verbal consent from one guardian for clonazepam 0.25 mg BID for anxiety, with side effects including sedation and drowsiness, and was signed only by an RN. Another consent form dated later listed both guardians’ names for an increased clonazepam dose but did not include a dosage, and again lacked the guardians’ signatures. Progress notes show that clonazepam 0.25 mg BID was ordered by the medical director and later increased to 0.5 mg BID for anxiety due to restlessness and behavioral issues. A behavior note documented that a guardian was initially apprehensive about increasing clonazepam due to concern about sedation but, after discussion about the care plan and behaviors, stated they would follow the doctor’s recommendations and that a psychotropic consent was signed and filed, although the form itself did not contain the guardians’ signatures. Interviews with the co‑guardians and staff further demonstrated inconsistencies and lack of reliable consent practices. The co‑guardians stated they were clear that they did not want the resident sedated and specifically did not consent to quetiapine or clonazepam, and that they were not contacted on the dates the facility documented consents for these medications. One guardian reported telling the facility at a care conference that he did not want the resident sedated or “drugged,” while the SSD stated the guardians did not mention not wanting psychotropic medications. RN C reported he obtained verbal consent from one guardian for clonazepam but acknowledged the other guardian opposed the medication and that he entered a late progress note about the consent at the DON’s direction weeks later. RN F reported he completed the consent form for the clonazepam dose increase and that the guardian was reluctant due to fear of sedation. The DON stated that verbal consents were documented on forms and that physical signatures were not obtained because the guardians did not visit often, and confirmed that once verbal consent was obtained, they did not pursue physical signatures. The visitor log showed the guardians did visit on at least two dates during the relevant period, but no signed consents from them were present in the record.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with severe cognitive impairment, dementia, blindness, and full-care needs had no listed family or representative in the record, and staff reported no known visitors or guardian. The SW said guardianship had not been pursued, while the DON and NP acknowledged the resident could not make care decisions and that no orders designated a guardian or representative. The facility’s Resident Rights policy stated that the resident has the right to have a legal representative.
A resident with impaired cognition had a family member designated as POA with authority over health care and related decisions. The POA, concerned about the resident’s care, repeatedly requested the resident’s medical records but was directed to Medical Records and required to complete written forms, unlike residents who could obtain records via oral request. The POA initially completed the form incorrectly and was told to redo it; the corrected paperwork was not submitted until after the resident’s death, at which point additional documentation was required. Staff, including MR personnel, acknowledged that the POA was authorized to act for the resident and that the resident lacked capacity to request records independently, yet the POA never received the records, resulting in a failure to allow the representative to exercise the resident’s rights.
A resident with dementia, ESRD on dialysis, impaired vision, and a severely impaired BIMS score had a designated responsible party, but the facility’s BOM bypassed this representative and obtained the resident’s signature on a retirement income address‑change form so the facility could receive pension checks directly. The BOM did not verify the resident’s cognitive status or consult the MDS nurse, despite acknowledging that low BIMS scores indicate inability to make informed decisions and that policy requires the representative’s signature. The resident’s representative, who worked part‑time at the facility, reported she was not contacted, questioned the authenticity of the printed signature, and stated the resident could not make such financial decisions. A CNA reported she did not witness the resident sign the form and described the resident’s cognition as poor, while the Administrator maintained that the resident could make his own decisions regardless of the low BIMS score, resulting in the facility failing to honor the representative’s authority.
Failure to Refer Incapacitated Resident for Patient Representative: A resident with bipolar disorder, anxiety disorder, and schizoaffective disorder was documented by the H&P as lacking capacity to understand and make decisions, while the admission record listed the resident as self-responsible. The SSD stated the resident had no family or designated decision-maker and was never referred to OLTCPR, despite facility policy requiring notification when no representative could be found. The DON stated the resident needed a representative, such as a family member, friend, or OLTCPR appointee, to assist with medical decisions and care oversight.
A resident with severe cognitive impairment and Korsakoff’s dementia repeatedly engaged in close physical and sexualized contact with another resident, including hand-holding, kissing, wandering together, attempts to leave the unit, and being found in the other resident’s bed with his pants unbuttoned and exposed. The resident’s daughter, acting as POA and documented decision maker, had clearly and repeatedly instructed staff that she did not want her father around the other resident and that any contact between them should not be permitted or encouraged. Despite these directives, staff continued to allow the two residents to be together, and the POA found them sitting closely together and holding hands after the bed incident, while leadership acknowledged that the two residents were always together and that the other resident was considered too difficult to redirect.
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 verify authority of resident representative
Penalty
Summary
The facility failed to obtain documentation showing that Resident #13’s representative had been delegated the authority to exercise the resident’s rights, and it did not verify that any court-appointed representative had authority for the specific decision-making at issue. Resident #13 was admitted with diagnoses including cerebral infarction, bipolar disorder, schizoaffective disorder, altered mental status, legal blindness, malignant neoplasm of the larynx, dementia, and cognitive communication deficit. The record showed severe cognitive impairment, with a BIMS score of 02, and the care plan stated that he had impaired cognition, was at risk for further decline, and needed supervision and assistance with all decision making. The resident’s face sheet did not list any family members or resident representatives. A progress note stated that he was a new admit, was blind, required full care, and had no family member listed on the admission sheet. During observation, Resident #13 was lying in bed and did not respond to the surveyor’s questions. CNA staff stated they had never seen him have visitors and were not aware of any family members or resident representative. The social worker stated that the facility had not pursued guardianship, that care plan meetings were held in the resident’s room, and that the resident did not participate because he could not make decisions for himself. The DON stated that a resident who cannot communicate should have a guardian or representative to inform staff of the resident’s wishes and for proper care, and that if there is no family or representative, the facility must reach out to the physician to make sure the resident has a representative. The NP stated that Resident #13 could communicate immediate needs but not make decisions about care plans or activities, had no known family members or guardians, and that there were no orders designating anyone as guardian or representative. The facility’s Resident Rights policy stated that the resident has the right to have a legal representative.
Failure to Honor Resident’s POA Request for Medical Records
Penalty
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.
Failure to Honor Resident Representative’s Authority in Financial Decision‑Making
Penalty
Summary
The deficiency involves the facility’s failure to recognize and honor the authority of a resident’s representative in financial decision‑making, despite the resident’s severe cognitive impairment. The resident was a 97‑year‑old male with dementia, end‑stage renal disease requiring dialysis, restlessness and agitation, hypertension, impaired vision, and a BIMS score of 3 indicating severe cognitive impairment. His care plan identified impaired cognitive function/dementia and directed staff to monitor and report changes in decision‑making ability and mental status. The face sheet listed a family member as the responsible party. During observation, the resident appeared flustered, had difficulty hearing, and was unable to understand and respond to surveyor questions, making interview attempts unsuccessful. The Business Office Manager (BOM) learned from the state that the resident had additional retirement income, which increased his monthly liability for room and board and resulted in an outstanding balance. The BOM reported that the responsible party had been keeping the extra retirement check and had entered into a promissory note to pay the balance. Instead of obtaining the responsible party’s signature, the BOM approached the resident directly in the hallway with a retirement income address‑change form so the facility could receive the retirement checks. The BOM stated she assumed the resident could make his needs known and did not verify the resident’s BIMS score or consult the MDS nurse, despite acknowledging that a low BIMS score would indicate the resident was not cognitively able to make an informed decision and that policy and procedure required obtaining the responsible party’s or appointed family member’s signature. The resident’s representative reported she did not understand why the BOM did not contact her at the facility where she worked part‑time and stated she believed the resident could not make such financial decisions due to his BIMS of 3. She also questioned the authenticity of the resident’s signature on the address‑change form, noting that the signature was printed while the resident normally signed in cursive. The BOM claimed a CNA had witnessed the signature, but the CNA stated she never saw the resident sign the form and only saw the BOM later waving the paper and saying she had obtained a signature. The CNA also described the resident’s cognitive status as poor, with difficulty remembering recent events and uncertainty about whether he could understand what he was signing. The Administrator stated that the resident could make decisions for himself regardless of the low BIMS score and that the state would have to deem a resident incompetent by court for the facility to take over financial responsibility, reinforcing that the facility treated the resident’s signature as valid rather than deferring to the designated representative.
Failure to Refer Incapacitated Resident for Patient Representative
Penalty
Summary
The facility failed to submit a referral to the Office of the Long-Term Care Patient Representative (OLTCPR) for one sampled resident who lacked decision-making capacity and had no legally authorized decision-maker. Resident 28 was admitted with diagnoses including bipolar disorder, anxiety disorder, and schizoaffective disorder. The admission record identified the resident as self-responsible, while the History and Physical stated the resident did not have the capacity to understand and make decisions. The Minimum Data Set also documented delusions and assistance needs with multiple activities of daily living. During interview, the Social Services Director stated that when a physician determined a resident lacked capacity, the facility would first try to locate next of kin or another decision-maker, and if none was available, a referral would be sent to the OLTCPR. The Social Services Director also stated the resident would be placed under the bio-ethics committee while waiting for a representative. However, the Social Services Director acknowledged that Resident 28 did not have the capacity to make medical decisions when admitted and was never referred to the OLTCPR. The Director of Nursing stated that when a resident lacked the capacity to understand or make decisions, the facility was responsible for ensuring the resident had a representative, such as a family member, friend, or an appointed representative from the OLTCPR. The facility policy titled Lack of Capacity Process stated that after 72 hours, if no patient representative could be found, the facility would notify the Office of Patient Representative to assign one. The California Department of Aging webpage cited in the report stated that OLTCPR provides trained public representatives for residents who lack decision-making capacity and have no legally authorized surrogate.
Failure to Honor POA Decisions Regarding Resident-to-Resident Physical/Sexual Contact
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s legal representative was able to exercise decision-making rights regarding the resident’s physical and sexual contact with another resident. Resident 12, who had Korsakoff’s dementia and was assessed as severely confused but independently ambulatory, had a documented power of attorney (POA) held by his daughter, identified as Family Member 1. Clinical records showed repeated instances of close physical contact between Resident 12 and Resident 11, including hand-holding, kissing, walking together, and attempts to leave the unit together. A quarterly MDS dated March 18, 2026, confirmed Resident 12’s severe cognitive impairment. Nursing notes from December 14 and December 29, 2025, documented that Resident 12 was talking with, holding hands with, kissing, and wandering the unit with Resident 11, and that they were trying to leave the unit together. On March 12, 2026, a nurse’s note documented that Resident 12 was found in Resident 11’s bed next to her with his pants unbuttoned and exposed. When the facility notified his daughter/POA, she was angry because she had previously been told that the residents would be separated. In an interview, Family Member 1 stated that in early December, shortly after admission, staff had informed her that Resident 11 had attached herself to Resident 12 like he was her boyfriend, and she clearly communicated that she did not want her father around Resident 11 due to his age and marital status. She reported that during multiple visits, Resident 11 followed them and told Resident 12 they needed to leave together, and that she had explicitly requested that they be separated and that contact between them not be permitted or encouraged. Despite this, when she arrived at the facility after the March 12 incident, she found Resident 12 sitting with Resident 11 at the nurse’s station, holding hands with her head on his shoulder. The Assistant DON confirmed that Resident 11 believed Resident 12 to be her boyfriend, that they were always together, and that although the daughter did not want them together, staff found Resident 11 too difficult to redirect.
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.
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