Failure to Complete Admission Paperwork for Resident
Penalty
Summary
The facility failed to complete required admission paperwork for one resident upon admission. According to the facility's own admission policy, residents or their legal representatives must be oriented to various policies and receive a copy of the admissions agreement, which is to be signed and filed in the resident's chart. Record review revealed that for this particular resident, who was admitted with diagnoses including osteomyelitis, intracranial injury with loss of consciousness, quadriplegia, and depression, there was no completed admission paperwork in the electronic health record. This included missing documentation on privacy practices, antidiscrimination policy, grievance policy, resident rights, trust fund, financial agreement, smoking policies, resident care policies, and other required documents. Further review showed 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 had not been completed at the time of admission and that the resident's medical record was incomplete due to the absence of these documents.