Resident Admission SOP Template

1.Purpose

To admit each new resident smoothly and safely, gather accurate baseline information, and put an initial care plan in place before the first shift change.

2.Scope

Applies to planned admissions of new residents into assisted living or skilled nursing care. Emergency or hospital transfer readmissions are covered by a separate procedure.

Definitions

Baseline assessment

The initial evaluation of a resident's physical, cognitive and functional status completed at admission.

Care plan

A written plan describing a resident's needs and the specific tasks staff will perform to meet them, reviewed and updated regularly.

Responsible party

The family member or legal representative authorized to make decisions on behalf of the resident when needed.

3.Responsibilities

Admissions Coordinator

Collects intake paperwork, verifies insurance or payment source and coordinates the move-in day schedule.

Registered Nurse (RN)

Completes the baseline assessment, reconciles medications and builds the initial care plan.

Certified Nursing Assistant (CNA)

Assists the resident with settling into their room and reports observations from the first shift.

Family Member / Responsible Party

Provides history, belongings and signs required admission documents.

RACI matrix

R = Responsible, A = Accountable, C = Consulted, I = Informed

4.Materials and PPE

Materials, tools and systems

• →Admission agreement and consent forms
• →Baseline assessment tool in the EHR or paper chart
• →Medication reconciliation form
• →Room readiness checklist
• →Emergency contact and responsible party form

Personal protective equipment

• →Disposable gloves for the physical assessment

5.Procedure

1. 5.1

   Confirm the room is ready

   Admissions Coordinator

   Confirm the assigned room is clean, equipped with any needed mobility or safety equipment, and labeled with the resident's name before arrival.

2. 5.2

   Greet the resident and family

   Admissions Coordinator

   Greet the resident and family warmly on arrival, introduce the care team members present, and orient them to the immediate area.

3. 5.3

   Collect and verify admission paperwork

   Admissions Coordinator

   Collect the signed admission agreement, consent forms, insurance or payment information and emergency contact details, and confirm the responsible party's authority.

   Checkpoint: All required consent and financial forms are signed and verified before the baseline assessment begins.

4. 5.4

   Review medical history and recent records

   Registered Nurse (RN)

   Review hospital discharge summaries, physician orders and recent medical history provided by the family or transferring facility.

5. 5.5

   Reconcile medications

   Registered Nurse (RN)

   Compare the medication list from the transferring facility or family against current physician orders and resolve any discrepancy before the first scheduled dose.

   Warning: Do not administer a medication until any discrepancy between the transfer record and the physician's order is resolved.

6. 5.6

   Complete the baseline assessment

   Registered Nurse (RN)

   Assess the resident's physical condition, mobility, cognitive status, skin integrity and nutritional needs using the facility's standard assessment tool.

   Checkpoint: The baseline assessment, including a skin check, is completed and documented on the day of admission.

7. 5.7

   Identify immediate risks

   Registered Nurse (RN)

   Identify fall risk, elopement risk, allergies and any urgent care needs from the assessment, and communicate them to the care team right away.

8. 5.8

   Build the initial care plan

   Registered Nurse (RN)

   Create the initial care plan covering mobility assistance, dietary needs, medication schedule and any immediate risk interventions identified in the assessment.

9. 5.9

   Communicate the care plan to the shift team

   Registered Nurse (RN)

   Brief the certified nursing assistants and incoming shift on the new resident's care plan and any immediate precautions before the end of the admission day.

10. 5.10

    Help the resident settle in

    Certified Nursing Assistant (CNA)

    Help the resident unpack, set up personal items and orient them to the call system, bathroom and dining schedule.

11. 5.11

    Observe and report the first shift

    Certified Nursing Assistant (CNA)

    Observe the resident through the first shift for adjustment, appetite, sleep and any signs of distress, and report findings to the nurse.

12. 5.12

    Follow up with the family

    Admissions Coordinator

    Contact the responsible party within the first day or two to confirm the resident is settling in and address any questions about the care plan.

6.Quality checks

• →Baseline assessment is completed and documented on the day of admission.
• →Medication reconciliation is completed before the first scheduled dose.
• →The care plan is communicated to the shift team before shift change.
• →Consent and financial forms are signed and on file before admission is considered complete.

7.Records

• →Signed admission agreement and consent forms
• →Baseline assessment documentation
• →Medication reconciliation form
• →Initial care plan

8.KPIs

• →Percentage of admissions with same-day baseline assessment completed
• →Medication reconciliation completion rate before first dose
• →Time from admission to initial care plan communicated to staff
• →Family follow-up completion rate within 48 hours

9.Common mistakes

• →Administering a scheduled medication before reconciling it against the physician's order.
• →Skipping the skin check during the baseline assessment.
• →Not briefing the incoming shift on a new resident's care plan and risks.
• →Leaving consent forms unsigned until after the resident has already moved in.

10.Revision history