Failure to Ensure Resident Rights in Admission and Transfer Processes
Penalty
Summary
The facility failed to ensure that residents with cognitive impairments or legal guardianship had their rights upheld during the admission and transfer processes. Specifically, one resident with a moderate cognitive impairment, as indicated by a BIMS score of 11 and diagnoses including traumatic brain injury and mood disorder, signed the admission notice agreement despite lacking the capacity to understand its terms. Staff interviews confirmed that this resident struggled to comprehend the billing process and did not have the capacity to understand the admission agreement. Another resident, who had a court-appointed guardian due to an intellectual disability and schizoaffective disorder, also signed admission paperwork instead of the guardian, contrary to legal requirements. Additionally, the facility did not provide residents or their representatives with a choice regarding transfer destinations for three residents. One resident with severe cognitive impairment and Alzheimer's disease was transferred to another facility without the representative being informed of options or being contacted by the original facility. Another resident with multiple chronic conditions was transferred without the representative being involved in the selection of the new facility. A third resident, with severe cognitive impairment and schizophrenia, was also transferred without the representative being informed or given a choice, and the representative only learned of the transfer from the receiving facility. These deficiencies were identified through review of facility policies, resident records, and staff and representative interviews. The findings indicate that the facility did not ensure informed consent or resident choice in key processes, particularly for residents with cognitive impairments or those under guardianship, as required by federal and state regulations.