Failure to Complete Required Quarterly Nursing Assessments
Penalty
Summary
The facility failed to ensure that the medical record for one resident was accurate and complete, as required by accepted professional standards. Specifically, multiple required quarterly nursing assessments—including those for bed rails, bowel and bladder, elopement, falls, lift and transfer, self-administration of medications, smoking, vital signs and pain, Braden (skin assessment), and Section GG of the MDS—were not completed as scheduled for the resident. Facility policy required these assessments to be conducted quarterly, annually, upon significant change of condition, post-fall, and as needed. Review of the resident's medical record confirmed that the last completion dates for most assessments were several months prior, and some assessments were missing for the current quarter. Interviews with the MDS Coordinator and MDS Nurse confirmed that the assessments were not current and acknowledged that they should have been completed according to facility policy. The MDS Nurse stated that although the quarterly MDS could still be transmitted, the associated nursing assessments were not up to date and were considered to be for facility use. The MDS Coordinator verified the missing assessments and stated that the resident's intermittent absences from the facility did not excuse the lack of quarterly assessments. The Administrator and ADON were informed of and acknowledged these findings.