Failure to Provide Timely Admission Agreements and Notice of Rights
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with notice of rights, rules, services, and charges prior to or upon admission, as required by facility policy. The Admissions Director stated that the admission agreement is very important because it includes information on resident rights, advance directives, facility and Ombudsman information, arbitration, and expectations, and that it should be signed within 72 hours of admission. However, record review showed that one resident, who was self-responsible and had an emergency contact listed, was admitted on a specified date and transferred to the hospital after a medical emergency, yet the state-specific admission agreement was not signed by the resident representative until eight days after admission. Another self-responsible resident with an emergency contact listed had no signed admission agreement in the clinical record, as confirmed by the ADON during concurrent interview and record review. For a third self-responsible resident, records showed admission on a specified date and discharge home on another date, with the emergency contact listed; the resident’s representative reported that the admission agreement was only given on the day of discharge, and that the resident and family were unaware of the care and services provided while at the facility. The state-specific admission agreement for this resident was dated the day the resident went home. For a fourth self-responsible resident, the admission agreement was signed more than one month after admission. Review of the facility’s policy and procedure titled “Admission Agreement,” last revised December 2025, indicated that each resident must have an admission agreement signed and dated by the resident or resident representative at the time of admission and filed in the clinical record, which did not occur for these four of five sampled residents.
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