Failure to Maintain Admission Documentation
Penalty
Summary
The facility failed to maintain proper admission documentation for a resident, identified as Resident R100. This deficiency was discovered through a review of resident records, admission documentation, and staff interviews. Resident R100 was admitted with diagnoses including dementia, acute kidney failure, and hypertension. The Resident Assessment Instrument 3.0 User's Manual, effective October 2019, was referenced, indicating that a Brief Interview for Mental Status (BIMS) is used to detect cognitive impairment. Resident R100's Admission MDS assessment dated 10/29/24 showed a BIMS score of 4, indicating severe cognitive impairment. Despite the admission of Resident R100 on 10/23/24, the clinical record review revealed that there was no admission packet for the resident. This was confirmed during an interview with the Regional Director of Clinical Services, Employee E6, who acknowledged that the admission paperwork for Resident R100 was never completed as required. This failure to maintain admission documentation is a violation of the facility's obligations under the specified regulations.
Plan Of Correction
R 100 has discharged. Unable to correct. To identify other residents that have the potential to be affected, the admissions director/designee completed a 15 day look back of new admission to ensure each resident has admission paperwork as required. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated staff on the regulatory requirements of F620 and ensuring new admissions have paperwork as required. To monitor and maintain ongoing compliance, the DON/designee will audit new admissions/readmission weekly x4 weeks then monthly x 2 to ensure they have paperwork as required. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.