Failure to Ensure RN Completion of Admission Assessments
Penalty
Summary
The facility failed to ensure that admission assessments for four residents were completed by a registered nurse (RN) as required by the Delaware State Code and the facility's own policy. Instead, licensed practical nurses (LPNs) completed multiple admission evaluations, including clinical admission, Braden Scale for pressure ulcer risk, lift/transfer evaluation, elopement evaluation, fall risk evaluation, dehydration risk evaluation, trauma informed care, and functional abilities and goals. The records for each resident showed that these assessments were documented and completed by LPNs at the time of admission or readmission, rather than by an RN. Interviews with facility staff, including the Director of Nursing (DON), confirmed that LPNs had performed several of the required admission evaluations. The deficiency was identified for all four residents reviewed for admission, with each case lacking RN-completed admission assessments as mandated. The findings were discussed with facility leadership during the exit conference.