Failure to Obtain Signed Admission Paperwork at Admission
Penalty
Summary
The facility failed to ensure that required admission paperwork was signed for a resident upon admission. Record review showed that a resident was admitted with multiple diagnoses, including transient cerebral ischemic attack, heart failure, atrial fibrillation, hypertension, obstructive sleep apnea, peripheral autonomic neuropathy, anxiety disorder, abnormalities of gait and mobility, dysphagia, insomnia, muscle weakness, essential tremor, and foot drop. The resident was assessed as having intact cognition. During the investigation, it was found that the facility did not have a signed admission Agreement for this resident, and the responsible party was contacted to complete the paperwork after the fact. Interviews with the administrator confirmed that the admission Agreement was not completed at the time of admission, and the omission was discovered during an audit of admission Agreements. The administrator acknowledged that the document was not lost but had never been generated or signed. The facility's policy required a completed admission application, including financial disclosure and supporting documents, before review by the admissions team. The responsible party for the resident confirmed being contacted by the facility to sign the admission Agreement, as it had not been provided during the admission process.