Failure to Timely Initiate Admission Orders for New Admission
Penalty
Summary
The facility failed to ensure that admission orders were entered and implemented in a timely manner for a newly admitted resident with multiple serious medical conditions, including acute myocardial infarction, coronary angioplasty implant and graft, heart failure, COPD, and psychosis. Upon arrival at approximately 9:00 p.m., the resident was not acknowledged or assessed by licensed staff for over two hours. The assigned LVN was unaware of the resident's admission until discovering the individual in bed during rounds at approximately 11:30 p.m. No admission packet or hospital orders were available or processed during this time, and no admission orders were entered into the electronic system. Interviews with staff revealed that admissions frequently occurred during shifts without an RN supervisor present, contributing to lapses in the admission process. The facility's policy required immediate initiation of admission orders and assessment upon a resident's arrival, including reconciliation of medications and communication with the attending physician. The administrator confirmed that the expectation was for admission orders to be initiated within 30 minutes of arrival and acknowledged that this protocol was not followed in this instance.