Failure to Maintain Proper Admission Documentation
Penalty
Summary
The facility failed to maintain proper admission documentation for three out of seven residents reviewed. Resident R1, who was admitted with a BIMS score indicating moderate cognitive impairment, was found to have signed their own admission packet, which is inappropriate given their cognitive status. This indicates a lapse in ensuring that residents with cognitive impairments are provided with the necessary support during the admission process. Additionally, the facility did not have signed admission packets for Residents R2 and R3. Resident R2 was admitted with diagnoses including encephalopathy, chronic kidney disease, and anemia, while Resident R3 was admitted with multiple rib fractures, a urinary tract infection, and lack of coordination. The absence of signed admission documentation for these residents suggests a failure in the facility's admission procedures, which is a violation of the residents' rights and the facility's admission policy.
Plan Of Correction
Residents R1, R2, R3 admission paperwork has been corrected. A whole house audit of correct admission paperwork will be completed for all residents to ensure that patients with a BIMS of 13 or higher or family have reviewed and signed all proper paperwork. Education with the Admission Director and Concierge on facility and state regulation of admission paperwork will be performed to ensure all paperwork is done upon admission. BIMS will be checked prior to the patient signing. Admissions paperwork will be signed by residents with a BIMS of 13-15, which indicates the patient is cognitively intact. Audits will be completed by Admissions or designee 3 times a week for 2 weeks, 2 times a week for 2 weeks, and 1 time a week for 2 weeks. This plan of correction will be monitored at the monthly Quality Assurance meeting until substantial compliance has been met.