Failure to Provide Admission Packet and Resident Rights Information
Penalty
Summary
The facility failed to establish and implement proper admission policies for a resident who was admitted and subsequently re-admitted following a hospital stay. Upon review, it was found that neither the resident nor the resident's family members completed or signed an admission agreement at the time of admission. The facility did not provide the required admission packet, which includes essential information such as resident rights, facility services, and policies. This omission was confirmed through interviews with the family member, the administrator, the admission coordinator, the receptionist, and the DON, all of whom acknowledged that the admission packet was not given due to the chaotic circumstances surrounding the resident's behavioral issues. The resident in question had a complex medical history, including psychoactive substance abuse, traumatic brain injury, and a recent traumatic subarachnoid hemorrhage with loss of consciousness. Upon admission, the resident exhibited acute mental status changes, including inattention, disorganized thinking, and mood disturbances such as depression, suicidal ideation, and aggressive behaviors. These behaviors led to the resident being sent to the hospital and subsequently returned to the facility, where the situation remained unstable. Interviews revealed that the facility's process for distributing admission packets was not followed. The admission coordinator was responsible for providing packets during weekdays, while the receptionist handled this task on weekends if instructed. However, during the resident's admission, the receptionist did not receive instructions to provide the packet, and the family member confirmed that no admission materials or resident rights information were received. The facility's own policies require that residents and families receive and sign for these documents, but this did not occur in this case.