Failure to Obtain Representative Signature for Resident Lacking Capacity
Penalty
Summary
The facility failed to ensure that a resident who lacked decision-making capacity had their admission packet e-signed by their designated representative. Instead, the admission assistant obtained an electronic signature from the resident, despite documentation in the resident's History and Physical (H&P) examinations indicating the resident did not have the capacity to understand or make decisions due to conditions such as metabolic encephalopathy, urinary tract infection, immunodeficiency, and dementia. The admission occurred after the resident was diagnosed with these conditions, and both the H&P dated shortly after admission and a subsequent H&P confirmed the resident's incapacity. During interviews and record reviews, both the admission assistant and the admission director acknowledged that the resident's representative should have been the one to e-sign the admission packet, as per the facility's policy and the resident's documented incapacity. The facility's policy states that a resident's representative has the right to exercise the resident's rights to the extent those rights are delegated. The failure to have the representative sign the admission documents resulted in the resident not being rightfully represented in important healthcare decisions.