Failure to Obtain Required Admission Consent From Resident’s Conservator
Penalty
Summary
The deficiency involves the facility’s failure to obtain admission consent in accordance with its policy and procedure titled “admission to the Facility.” One resident was admitted on a specified date with diagnoses including diabetes mellitus and hypertension. The resident’s History and Physical dated 12/12/2025 documented that the resident did not have the capacity to understand and make decisions, while the MDS dated 12/14/2025 indicated the resident was able to understand and be understood by others and required varying levels of assistance with ADLs, including supervision, moderate assistance, and maximal assistance for mobility and self-care tasks. Despite the resident’s documented need for assistance and questions about decision-making capacity, the facility proceeded with admission without obtaining consent from the resident or the responsible party. During an interview, the resident’s family member stated she was the court-appointed conservator and reported that the prior facility did not inform her that the resident was being transferred and that she did not give the admitting facility permission to take the resident. In a concurrent interview and record review, the Admission Coordinator acknowledged that the facility’s policy was not followed when the conservator’s consent was not obtained prior to admission and stated that the conservator’s admission consent should have been obtained to ensure the resident’s and conservator’s wishes were respected. Review of the facility’s admission policy dated 1/2023 showed that residents are to be admitted only upon written order of the attending physician and with the consent of the resident or responsible party, and that identifying paperwork for any appointed surrogate or representative must be presented prior to or upon admission. These requirements were not met in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.