Failure to Complete Required Assessments and Vital Signs Documentation After Resident Readmission
Penalty
Summary
The facility failed to complete required physical assessments and document vital signs for a resident who was readmitted following serious medical conditions, including cholecystitis, sepsis, and septic shock. Upon readmission, the clinical record did not include a physical assessment or vital signs on multiple consecutive days. While some pre- and post-dialysis assessments included partial vital signs, there were several days with missing documentation of both vital signs and physical assessments. Additionally, after the resident experienced bleeding from a leg wound and was sent to the emergency department, there was no documentation of an assessment or vital signs upon the resident's return. Progress notes indicated ongoing issues, such as copious drainage from leg wounds, poor circulation, and difficulty obtaining oxygen saturation readings, yet there was still a lack of documented assessments and vital signs. Interviews with the DON and ADON confirmed the absence of required documentation and assessments in the electronic health record. The facility's policy required staff to perform and document a full assessment and vital signs every shift, with no exceptions, especially when a change in condition was observed. Despite this, the required assessments and documentation were not completed for the resident.