Failure to Complete and Document Nursing Admission Assessment
Penalty
Summary
The facility failed to maintain complete and accurate clinical records in accordance with accepted professional standards for one resident. Specifically, nursing staff did not document the admission nursing assessment for a female resident with multiple complex diagnoses, including cerebral infarction, acute respiratory failure with hypoxia, diabetes, hematemesis, lack of coordination, gait abnormalities, hyperlipidemia, epilepsy, and COPD. The resident was moderately cognitively impaired and required assistance with personal care. The physician completed an admission physical assessment, but the nursing admission assessment was missing from the electronic record. During interviews, the resident reported not recalling being seen or checked by a doctor after admission and believed she did not receive her diabetes, insulin, or seizure medications during the first days of her stay. The Administrator, who is also an RN, confirmed that the nursing admission assessment was not completed or found in the electronic record, explaining that the admitting nurse had to leave due to a family emergency, and the Administrator and ADON took over. The Administrator verified physician orders and entered medications but acknowledged the absence of the required nursing assessment, which is used to develop the resident's care plan.