Incomplete Nursing Admission Assessment
Penalty
Summary
The facility failed to ensure that a resident's Nursing Admission Assessment was complete and accurately reflected the resident's status at the time of admission. Specifically, the assessment for a male resident with diagnoses including chronic gout, emphysema, and adjustment disorder with anxiety did not include information on behaviors, fall history, elimination status, gait/balance, bowel and bladder status, or a list of medications. The 5-day Minimum Data Set (MDS) was still in progress, and the clinical record lacked the required comprehensive assessment details as outlined in the MDS 3.0 Resident Assessment Instrument (RAI) Manual. During an interview, the Administrator confirmed that the assessment was incomplete and did not meet expectations for accuracy and thoroughness. The Administrator stated that the Director of Nursing (DON) was responsible for ensuring assessments were complete and that all staff had been trained and retrained on this process. The Admissions Nurse previously responsible for completing admission assessments was no longer employed due to performance issues, and a new employee had recently started. The facility did not have a specific policy for completing admission assessments accurately, relying instead on the assumption that the questions were self-explanatory.