Failure to Timely Evaluate Resident After Hospital Readmission
Penalty
Summary
A deficiency was identified when a resident who had recently returned to the facility following a hospitalization was not evaluated by a provider within the required timeframe. The resident, admitted with diagnoses including transient ischemic attacks, cerebral infarction, alcoholic cirrhosis of the liver, and depression, was noted to be cognitively intact and independent with activities of daily living prior to the hospitalization. Upon return, therapy documentation indicated the resident now required substantial assistance with daily activities, and the resident was on anticoagulant therapy with specific monitoring interventions outlined in the care plan. Despite these changes and the facility's policy requiring evaluation by a physician or APRN within forty-eight hours of admission or readmission, the resident was not seen by a provider until five days after returning from the hospital. The Director of Nursing confirmed the facility's policy and was unable to explain the delay. Review of the Public Health Code also confirmed the requirement for a comprehensive medical history and examination within forty-eight hours of admission.