Failure to Complete RN Assessment After Resident Incident
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) completed an assessment after an incident in which a male resident was found in the bed of a female resident. According to the Pennsylvania Nursing Practice Act and the facility's own risk management policy, an RN assessment should be documented in the clinical record following such incidents. However, review of the clinical record for the affected resident revealed no evidence that an RN assessment was performed after the event. The resident involved was cognitively impaired, with diagnoses including Alzheimer's Disease and dementia, and required moderate assistance from staff. The incident was brought to attention through a grievance filed by the resident's daughter, who reported that the male resident was only removed after the roommate called for staff for several minutes. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed that no RN assessment was completed at the time of the incident.