Incomplete and Late Documentation of Admission Assessment
Penalty
Summary
The facility failed to ensure that medical records were completed and accurate for one resident out of three sampled. Upon review, the Nursing Admission Screening/History for a resident admitted from the hospital and later discharged was found to be blank except for auto-populated vital signs. Key sections such as admission details, neurological status, social history, physical assessments, and medication information were not documented at the time of admission. The assessment remained incomplete and unlocked in the electronic medical record system until more than a month after the resident's discharge. On the day of the survey, a staff LPN/Unit Manager completed and locked the previously blank assessment at the request of the Chief Nursing Officer (CNO) to print the document. The LPN admitted to filling out the assessment despite not having performed the original admission, and the CNO confirmed that this was not appropriate practice. The CNO also acknowledged that the facility did not have a specific policy for documentation of admission assessments, and that documentation should have been completed within 72 hours of admission, not after discharge.