Failure to Inform Resident of Rights and Obtain Signed Admission Documents
Penalty
Summary
The facility failed to ensure that a resident was informed of her rights regarding treatment, financial liability, and resident rights upon admission. Record review showed that the resident, who was cognitively intact but had unclear speech and some communication difficulties, was admitted with diagnoses including amyotrophic lateral sclerosis, hemiplegia, dysphagia, and slurred speech. The facility's policy required that residents be informed of their rights both orally and in writing, in a language they understand, prior to or upon admission. However, the resident's admission agreement, which included consent to treat, was signed electronically by a representative whose information was incorrect, and the resident herself did not sign any documents. The Resident Rights form was not signed, and the financial expectations and insurance forms were either incomplete or blank. Interviews with the resident's family member revealed that the admission paperwork was received electronically but could not be signed due to incorrect information, and the resident never signed any forms herself. The Director of Hospitality/Interim Admissions Staff could not confirm when the paperwork was sent, and the Administrator stated that the consent to treat should have been signed upon admission but was not present in the physical chart. The Vice President of Operations confirmed that the admission packet was not signed at admission and that there was no documentation showing the resident or representative was informed of rights, benefits, or costs. The admissions staff responsible had resigned at the time of admission, contributing to the lack of proper documentation.