Failure to Complete Admission Assessments for Two Residents
Penalty
Summary
The facility failed to meet professional standards of care by not completing admission assessments for two residents. The Licensed Practical Nurse (LPN) and Registered Nurse (RN) job descriptions require comprehensive documentation, including admission assessments, but this was not adhered to for the residents in question. Resident R90, admitted with diagnoses of high blood pressure, hyperlipidemia, and lymphedema, did not have an 'Admission/Readmission Observation' assessment completed upon admission. Similarly, Resident R203, admitted with chronic obstructive pulmonary disease, chronic respiratory failure, and dependence on supplemental oxygen, also lacked this critical assessment. The absence of these assessments was confirmed during an interview with the Director of Nursing (DON), who acknowledged the facility's failure to provide care and services that meet professional standards. The deficiency was identified through a review of facility policies, job descriptions, clinical records, and staff interviews, highlighting a lapse in the facility's adherence to required documentation and assessment protocols for newly admitted residents.
Plan Of Correction
The facility cannot retroactively correct the admission readmission observation for Resident #90 and #203. A chart review was completed to ensure their needs were care planned. Moving forward, the facility will ensure admission readmission observations are completed as required. New admissions and readmissions have the potential to be affected. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated staff on the requirements to complete an admission assessment/observation. To monitor and maintain ongoing compliance, the DON/designee will audit new admissions/readmissions for admission observation completeness weekly x2, then monthly x2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.