Failure to Provide Notice of Resident Rights on Admission
Penalty
Summary
The facility failed to provide a notice of resident rights upon admission for one resident. According to the facility's own admission policy, residents or their representatives must be informed of their rights and facility policies both orally and in writing, with accommodations for impairments and language needs. The policy also requires written acknowledgment of this explanation to be documented in the admission agreement. Record review showed that for the resident in question, who was admitted with diagnoses including osteomyelitis, intracranial injury with loss of consciousness, quadriplegia, and depression, there was no documentation in the electronic health record indicating that the resident or their representative received or acknowledged the notice of rights at admission. Further review revealed that the resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had a designated health care power of attorney. Interviews with the Admissions Director confirmed that the admission paperwork, including the required notice of rights, had not been completed at the time of admission, and the medical record lacked the necessary documentation to show that the resident or their representative had received this information.