Failure to Ensure RN Completion of Admission and Post-Fall Assessments
Penalty
Summary
The facility failed to ensure that registered nurses (RNs) completed and documented required admission and post-fall assessments for two residents, as mandated by the Delaware State Board of Nursing Scope of Practice. For one resident admitted with dementia, all admission observations and assessments—including those related to language, hearing, speech, vision, and multiple body systems—were completed and documented by LPNs, with no evidence of RN involvement in the admission assessment process. The Director of Nursing confirmed that the documentation in question was part of the admission assessment, and the facility was unable to provide any RN-completed admission assessment for this resident. In a separate incident, another resident experienced a fall, and the post-fall assessment and documentation were completed solely by an LPN. The nurse's note and event report detailed the fall, observations, and follow-up, but there was no documentation of RN assessment or involvement. Interviews with staff confirmed that LPNs performed these assessments, which is outside their scope of practice according to state regulations.