Incomplete Admission Agreement for Deceased Resident
Penalty
Summary
A deficiency was identified when a resident admitted with advanced prostate cancer and metastases to the bone and brain did not have a completed and signed admission agreement upon entry to the facility. The resident was admitted on a Friday evening shift and was listed as his own responsible party. Attempts to complete the admission agreement were unsuccessful: the resident was asleep during the initial attempt, remained asleep during a follow-up, and later refused due to fatigue. The admission packet remained incomplete and unsigned up to the time of the resident's death. Additionally, the hospital facesheet listed two individuals as siblings, but it was later discovered they were not family members, and the resident's actual brother was only identified on the day of death. As a result, the resident's medical record lacked a completed and signed admission packet, which is a legal document outlining resident rights, facility policies, and healthcare services to be provided.