Failure to Complete Comprehensive Admission Assessment and Timely Pain Management
Penalty
Summary
The facility failed to provide an accurate and comprehensive admission assessment for one resident with multiple diagnoses, including unspecified dementia and legal blindness. Upon admission, documentation inconsistencies were noted across various records, including the care plan, admission notes, and progress notes. The resident's care plan indicated the need for a wanderguard for safety, but other records failed to accurately reflect the resident's cognitive impairment, visual impairment, and safety concerns. Additionally, the baseline care plan and progress notes did not document the presence of pain or injury, despite the resident having a red and swollen right hand and forearm, and a physician's order for immobilization of the right forearm with a splint and ACE wrap. Observations and interviews revealed that staff did not perform necessary assessments, such as vision and pain assessments, nor did they follow physician orders for immobilizing the resident's right forearm. The resident was observed to have visible swelling and redness in the right hand and forearm, and demonstrated difficulty lifting the affected arm. Despite these findings, there was no documentation of a right arm injury in the resident's hard chart, and the medication administration record showed that the resident did not receive a pain assessment or pain medication until several days after admission. Further interviews with staff indicated a lack of awareness and documentation regarding the resident's impairments and needs. The activities director did not engage with the resident during the initial interdisciplinary team meeting, and there was no documentation of activities provided. Facility policies required comprehensive admission assessments, including pain and functional assessments, but these were not completed as required, resulting in delayed interventions for the resident's pain and inadequate accommodation of the resident's cognitive and visual impairments.