Failure to Provide and Document Comprehensive Admission Rights
Penalty
Summary
The facility failed to provide a comprehensive review of admission rights and maintain complete admission documentation for one resident. Specifically, the facility's policy requires informing residents of their rights and responsibilities upon admission. However, for one resident with diagnoses including diabetes, dementia, and hypertension, the admission record lacked documentation of an admissions packet or discussion covering key topics such as patient portion liability, daily rate cost structure, resident rights, appeal rights, consent to treatment, Medicare and Medicaid processes, choice of ancillary services, bed hold policy, and consequences for non-payment. The resident's surrogate decision maker was identified, but there was no evidence that this information was communicated or documented as required. During interviews, medical records staff could only provide a single sheet from the resident's admission record, and the DON confirmed that the facility did not provide or maintain the required comprehensive admission documentation. This deficiency was identified through review of facility policy, resident records, admissions documentation, and staff interviews, and it was found to be out of compliance with state regulations regarding management, admission policy, and resident rights.