Missing Admission Paperwork for Residents
Penalty
Summary
The facility failed to ensure that admission paperwork, including admission agreements and consents, was present in the resident records for four of the sixteen sampled residents. During a review of the records for these residents, it was found that there was no documentation of the necessary admission paperwork, which includes admission consents and admission agreements/contracts. The deficiency was confirmed by the Administrator, who acknowledged that the admission paperwork for these four residents could not be located. The Administrator expressed uncertainty about what happened to the documents and indicated that the facility was in the process of obtaining new admission paperwork for the affected residents.
Plan Of Correction
1. Immediate action(s) taken for the resident(s) found to have been affected include: Facility contacted resident/representative and obtained new admission agreement for residents #7, #9, #11 and #15. 2. Identification of other residents having the potential to be affected: A facility wide audit was completed for all in-house residents. Review of medical records to verify and ensure admissions agreements were completed for all residents. Any resident found not to have an agreement was completed. 3. Actions taken/ systems put in place to reduce the risk of future occurrence include: Admissions department staff were educated to ensure admission agreements are completed and signed in a timely manner. Audits will be put in place. 4. How the corrective action(s) will be monitored to ensure the practice will not reoccur: The Director of Admissions/designee will conduct quality review of resident records to ensure admission agreements are completed and uploaded into resident records. Records of newly admitted residents will be monitored for Admission agreements completion and upload. Quality reviews will be completed once a week x8 weeks and then every 2 weeks x1 month. Quality reviews will be reviewed by the QAPI committee monthly x 3 months or until substantial compliance is met along with quarterly reviews.