Failure to Provide Timely Notice of Rights and Secure Admission Consents
Penalty
Summary
The facility failed to ensure that a resident and their representative were informed of their rights, rules, and responsibilities upon admission. Specifically, the clinical record did not show that the required admission paperwork—including the bed hold policy, contraband policy, consent for treatment, advance directive/code status consent, smoking policy, resident rights, influenza vaccination consent and education, and the facility admission agreement—was reviewed with the resident representative at the time of admission. Additionally, there was no documentation of a signed advance directives/code status consent form at admission. The resident in question was admitted with diagnoses including alcohol dependence, repeated falls, and anxiety disorder, and had severely impaired cognition, requiring moderate assistance with activities of daily living. The resident was hospitalized for alcohol withdrawal prior to admission and was initially identified as full code regarding resuscitation status. However, the care plan and physician orders regarding code status were inconsistent and not supported by timely, signed documentation from the resident or their representative. Interviews with facility staff revealed that the social worker was responsible for reviewing administrative paperwork, while the RN supervisor was responsible for clinical paperwork. The social worker acknowledged that, due to the resident's cognitive impairment, paperwork was reviewed with the resident's representative, but this did not occur until approximately one month after admission. Furthermore, the signed documents were not placed in the resident's paper chart or uploaded to the electronic record. The advance directive/code status consent form was not signed until six months after admission, contrary to facility policy requiring this to be completed upon admission.