Comprehensive Nursing Assessment Not Performed by RN at Admission
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including heart failure, atrial flutter, diabetes, and a cognitive communication deficit, was admitted to the facility. The initial comprehensive nursing assessment for this resident was completed and signed by an LPN, rather than a registered nurse (RN). According to the California Association of Long-Term Care Medicine and state regulations, an LPN is permitted to conduct only basic patient assessments and is not authorized to perform comprehensive health assessments, which are required to be completed by an RN. A review of the facility's policy and procedure for admissions indicated that a licensed nurse should perform a complete assessment of body systems and complete the admission assessment form and nursing notes. However, during an interview, the Assistant Director of Nursing confirmed that there was no evidence of RN oversight during the admission assessment for this resident, and acknowledged that such oversight should have been present.