Failure to Complete Timely Admission and Fall Risk Assessments, and Maintain Accurate Medical Records
Penalty
Summary
The facility failed to ensure timely and accurate completion of admission assessments and routine risk assessments, as well as proper maintenance of medical records for multiple residents. For one resident, the admission assessment was not completed upon entry, and the information present was outdated, having been carried over from a previous admission. Physician orders for medications were not entered until at least ten hours after admission, and not all ordered medications were entered into the system. Additionally, when the resident experienced a medical emergency and was sent to the hospital, no paperwork accompanied the transfer, and staff were unable to locate the initial nursing assessment at the time of transfer. Another resident was readmitted to the facility but did not have a fall risk assessment completed upon re-entry or on a quarterly basis, as required. The only fall risk assessment documented during the current stay was completed after the resident experienced an unwitnessed fall. The quarterly Minimum Data Set (MDS) assessment for this resident also failed to reflect the fall history accurately. The DON confirmed that no admission or quarterly fall risk assessments had been completed since the resident's re-entry, except for the one conducted after the fall. A third resident also did not receive a fall risk assessment upon readmission or on a quarterly basis. The only assessments documented were at initial admission and after the resident sustained an unwitnessed fall. The facility's policy required fall risk assessments to be completed on admission, quarterly, and with significant changes, but this was not followed. The DON confirmed the lack of required assessments for this resident as well. These findings demonstrate a pattern of non-compliance with accepted professional standards for safeguarding resident-identifiable information and maintaining accurate, up-to-date medical records.