Failure to Provide Resident Rights and Admission Packet Upon Admission
Penalty
Summary
The facility failed to provide a notice of rights and services to a resident prior to or upon admission, as well as during the resident's stay, and did not ensure receipt and written acknowledgment of such information. The resident in question was admitted with a history of psychoactive substance abuse, traumatic brain injury, and a recent traumatic subarachnoid hemorrhage. Upon admission and subsequent readmission, neither the resident nor the family member received the required admission packet or information regarding resident rights, as confirmed by interviews with the family member, administrator, and other facility staff. The deficiency was further substantiated by staff interviews, which revealed that the admission packet, containing essential information such as resident rights, consent forms, and facility policies, was not provided due to the chaotic circumstances surrounding the resident's behavioral issues. The administrator acknowledged that the admission packet was not given because of the behavioral incidents that occurred shortly after admission. The receptionist, who was responsible for distributing admission packets on weekends, stated she did not receive instructions to provide the packet to the resident or family member during the relevant period. Facility policies reviewed indicated that it is standard procedure to provide residents and their representatives with written information about their rights and services, and to obtain a signed acknowledgment for the clinical record. However, in this case, the process was not followed, and the required documentation was not present in the resident's record. The family member also reported not receiving any incident report or information about the resident's rights, and was not informed about the process for appealing a discharge.