Health inspection·April 26, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure resident representatives were involved in medical decision making for the resident. This affected one (Resident #46) of three sampled residents. The census was 44. Residents Affected - Few Findings include: Resident #46 was admitted to the facility on [DATE]. His diagnoses were dementia, elevated white blood cell count, squamous cell carcinoma, hypertension, type II diabetes, asthma, hyperlipidemia, anxiety disorder, and muscle weakness. Review of the face sheet revealed Resident' #46's wife was his durable power of attorney (DPOA). Review of the Informed Consent for Psychiatric Assessment and Treatment, dated 10/19/22, revealed the psychiatric consultation company documented that Resident #46 gave verbal consent to complete the initial psychiatric assessment and complete psychiatric care as needed. There was no documentation Resident #46's wife had been notified about this assessment or further psychiatric care provided. Review of his minimum data set (MDS) assessment, dated 02/08/23, revealed he was severely cognitively impaired. Review of Resident #46 psychiatric consultation report, dated 02/21/23, revealed the psychiatric consultation company completed a psychiatric care note regarding a psychiatric assessment and follow-up. There was no documentation that Resident #46's wife had been notified of or consulted about this psychiatric assessment. Review of the progress notes from 06/30/22 through 03/03/23, revealed multiple entries in which the facility notified the resident's wife about changes in his condition and took direction from the representative on the type of care that would be desired. During interview on on 04/26/23 at 12:50 P.M., the Administrator and Regional Director #200 stated the psychiatric services were contracted. The psychiatric consultation company did the initial assessment and completed the consent process for each resident. They stated they knew the outside contractor would be completing the initial assessment process with residents to determine their psychiatric needs. They confirmed they have no documentation that Resident #46's wife was notified and consulted about psychiatric services for Resident #46. This deficiency represents non-compliance investigated under Complaint Number OH00141915. Page 1 of 2 366038 366038 04/26/2023 Greenfield Skilled Nursing and Rehabilitation 238 South Washington Street Greenfield, OH 45123

F 0573 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Let each resident or the resident's legal representative access or purchase copies of all the resident's records. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and policy review, the facility failed to provide a resident's medical record at the request of the resident's Durable Power of Attorney (DPOA). This affected one (Resident #46) of three sampled residents. The census was 44. Findings Include: Resident #46 was admitted to the facility on [DATE] Review of his minimum data set (MDS) assessment, dated [DATE], revealed he was severely cognitively impaired. Review of the face sheet in Resident #46's medical record listed his wife as his DPOA. Review of the medical records request log documented Resident #46's wife requested the medical records of Resident #46 on [DATE]. The log documented that the request was canceled, but listed no date of the cancellation. Review of a written document by Regional Director #200, dated [DATE], revealed she spoke with Resident #46's wife on that day about the records request they had made. Regional Director #200 stated they had received the request form from Resident #46's wife and they would start the process of speaking with Resident #46 primary care physician to determine if Resident #46 was incapacitated. Resident #46's wife stated she would like the requested documentation prior to Resident #46's imminent death. Review of Resident #46 progress notes, dated [DATE], revealed Resident #46 expired. There was no documentation that Resident #46's wife had ever received his medical record as requested. During interview on [DATE] at 12:50 P.M., the Administrator and Regional Director #200 confirmed Resident #46's wife first requested his medical records on [DATE]. They both confirmed they did not provide the medical records to Resident #46 family because they did not have any formal documentation stating Resident #36 was incapacitated. They stated the facility needed to have documentation of a formal medical records request, and documentation from Resident #46 primary care physician that he was incapacitated. They confirmed progress notes documented Resident #46's wife had been involved in decision making related to his care and she was his DPOA. Review of facility policy titled Access to Personal and Medical Records, dated [DATE], revealed each resident has the right to access and/or obtain copies of his or her personal and medical records upon request. Access to the resident's personal and medical records will be provided to the resident within 24 hours (excluding weekends and holidays) of his or her request. The resident may obtain a copy of his or her personal or medical record within two business days of a written request. The resident, or his/her legal representative, may grant others the right to access the resident's records if such request is made in writing and identifies the information that is the be released and to whom the information is to be released. This deficiency represents non-compliance investigated under Complaint Number OH00141915. 366038 Page 2 of 2