Failure to Document Admission Nursing Note After Comprehensive Assessment
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure that a nursing note was recorded in the medical record for one resident following the completion of their comprehensive admission assessment. According to the facility's policy and procedure for admissions, licensed nurses are required to perform a complete assessment of body systems and document their findings in both the admission form and nursing notes. However, a review of the electronic medical record revealed that no admission nursing note was present for the resident. During an interview, the Assistant Director of Nursing acknowledged the absence of the required admission nursing note and confirmed that it should have been completed.