Incomplete H&P: Omission of Mental Status Assessment
Penalty
Summary
A physician assistant failed to complete a comprehensive History and Physical (H&P) examination for a resident by omitting an assessment of the resident's mental status. The resident was admitted with multiple diagnoses, including a nondisplaced intertrochanteric fracture of the left femur, respiratory failure, and metabolic encephalopathy. The Minimum Data Set (MDS) assessment indicated that the resident had moderately impaired cognition and required varying levels of staff assistance for daily activities. However, the H&P completed shortly after admission did not document any evaluation of the resident's mental status. During a review of the resident's records, the Director of Nursing confirmed that the H&P was incomplete and acknowledged that a mental status assessment should have been included. The facility's policy requires a comprehensive physical examination, including mental status, to be documented within a specified timeframe after admission. The lack of a documented mental status assessment resulted in an incomplete evaluation of the resident's overall condition.