|§483.10(b)(3) In the case of a resident who has not been adjudged incompetent by the state court, the resident has the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law. The same-sex spouse of a resident must be afforded treatment equal to that afforded to an opposite-sex spouse if the marriage was valid in the jurisdiction in which it was celebrated.|
(i) The resident representative has the right to exercise the resident's rights to the extent those rights are delegated to the representative.
(ii) The resident retains the right to exercise those rights not delegated to a resident representative, including the right to revoke a delegation of rights, except as limited by State law.
§483.10(b)(4) The facility must treat the decisions of a resident representative as the decisions of the resident to the extent required by the court or delegated by the resident, in accordance with applicable law.
§483.10(b)(5) The facility shall not extend the resident representative the right to make decisions on behalf of the resident beyond the extent required by the court or delegated by the resident, in accordance with applicable law.
§483.10(b)(6) If the facility has reason to believe that a resident representative is making decisions or taking actions that are not in the best interests of a resident, the facility shall report such concerns when and in the manner required under State law.
§483.10(b)(7) In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident devolve to and are exercised by the resident representative appointed under State law to act on the resident's behalf. The court-appointed resident representative exercises the resident's rights to the extent judged necessary by a court of competent jurisdiction, in accordance with State law.
(i) In the case of a resident representative whose decision-making authority is limited by State law or court appointment, the resident retains the right to make those decisions outside the representative's authority.
(ii) The resident's wishes and preferences must be considered in the exercise of rights by the representative.
(iii) To the extent practicable, the resident must be provided with opportunities to participate in the care planning process.
Based on review of clinical records and staff interview revealed the facility failed to ensure that individuals making medical and financial decisions for residents were legally authorized to do so and to assure that these decisions did not extend beyond the extent allegedly extended by the resident and that the wishes and preferences of the resident were considered to the extent possible (Resident CR1) for one out of five residents reviewed.
A review of the clinical record revealed that Resident CR 1 was admitted to the facility on September 29, 2018. Clinical record review revealed that a friend stated that she was acting as the financial and medical power of attorney for the resident and had signed all of the resident's admission paperwork. However, there was no documented evidence that the resident was adjudicated incompetent by the court or identified to have impairments/limitations, which prevented her from making sound decisions regarding her care and finances at the time of admission.
A review of the resident's MDS (minimum data set - a federally mandated assessment conducted periodically to plan resident care) dated October 5, 2018, revealed that the resident's cognition was intact. The resident's BIMS(brief interview for mental status, the cognitive portion of the assessment) with a score of 15/15.
Further review of the resident's clinical record revealed that this friend had instructed the facility not to allow the resident to sign any documents. On October 5, 2018, the resident's friend expressed concerns with the resident's family attempting to come into the facility to take the resident out on a leave of absence. The friend also stated that the resident "acts mean" when she talks to certain family members, but she did not wish to take the resident's cell phone away from her.
Documentation revealed that on October 16, 2018, the resident's friend stated that she did not want the resident to know that her placement at the facility was to be long term. She also expressed concerns with the resident's niece. She stated she did not want to restrict contact with her, but she did not want her to receive any information about the resident or to allow the resident to go out on a leave of absence with the resident's niece.
A review of the resident's clinical record revealed the resident had completed a Living Will prior to admission, and had made this particular niece her second decision maker if the resident's friend could no longer serve.
On December 7, 2018, the resident's nephew came into the facility and attempted to discuss the resident's placement at the facility. During this visit, he expressed concerns with the actions of the resident's friend. The facility contacted the resident's friend and she stated that she did not want to restrict the resident's contact with this nephew because "she loved him."
A Social Service referral was made on December 14, 2018, because the resident was upset regarding her finances. The resident was reminded that her friend was handling her finances. The facility then contacted the resident's friend to make her aware of the resident's concerns. The resident's friend responded that this was not a new behavior for the resident.
On January 21, 2019, Social Services staff met with the resident at the resident's request. The resident stated that she spoke with her nephew regarding transfer to another long term care facility. The Social worker again noted there were complex family dynamics involved and this nephew did not have the ability to participate in decisions for the resident. The resident's friend was contacted and she stated that she did not want to pursue the resident's discharge.
Social Services completed an MDS/BIMS assessment on the resident on April 11, 2019. The resident's cognition remained intact with a score of 13/15. Subsequent MDS and BIMS assessments dated July 3, 2019, and September 10, 2019, also revealed that the resident's cognition remained intact with scores of 15/15 at each assessment.
On September 20, 2019, Social service progress notes revealed the resident was "anticipating" discharging to another skilled facility. A review of nursing progress notes revealed that the resident was discharged that day.
A review of submitted communication, revealed that the resident's friend did not want the resident to be made aware of her discharge to another facility, until the morning of her discharge. She also requested that her name (the resident's friend) not be mentioned as the organizer of the resident's discharge. The Nursing Home Administrator, who was no longer employed at the facility, instructed the Social Worker that it was the resident's right to know she was leaving and the resident was informed on the afternoon of September 19, 2019, that she would be leaving the facility.
According to review of interdisciplinary progress notes, the resident was discharged from the facility at 12:00 p.m., on September 20, 2019.
A review of the resident's clinical record, revealed no evidence that the facility had documented proof that the resident's friend did in fact have a durable power of attorney, to make medical and financial decisions for the resident.
The facility also failed to determine, if this individual did in fact have this legal authority and had determined that it was effective immediately or when the resident no longer had the capability to exercise her rights.
There was no indication, that despite the resident's intact cognition, that the facility had attempted to determine from the resident, her wishes, preferences or account of her personal history. The facility continually differed to the resident's friend, even when the resident had expressed concerns about her finances.
There was no indication that the facility made attempts, to allow this capable, cognitively intact resident, to participate in any of the decisions regarding her care or with whom she wished to interact.
When interviewed on December 4, 2019 at 2:45 p.m., the licensed nursing home administrator was unable to provide documented evidence that the facility had documented evidence that the resident's friend had health and financial power of attorney for the resident.
28 Pa. Code: 201.18(a)(b)(2)(e)(1) Management
28 Pa. Code: 201.19 (a)(j)(l)(1)(2) Resident Rights.
| ||Plan of Correction - To be completed: 02/02/2020|
1. Resident no longer resides at Bloomsburg Care and Rehab Center.
2. An audit will be conducted on 30% of current residents to determine that individuals making medical and financial decisions for residents are legally authorized to do so and to verify
that these decisions did not extend beyond the extent allegedly extended by the resident and
that the wishes and preferences of the resident were considered to the extent possible.
3. Upon admission, the admissions coordinator/designee will verify that resident's living will, POA for both medical and financial and POLST are available and communicate to the IDT.
4. Admissions/designee will audit each new admission to verify the facility has been provided accurate information regarding POA, both financial and medical, POLST and living will.
5. Admissions/designee will report findings to QAPI x3 months.