Admission Assessment and Care Plan Not Completed by RN
Penalty
Summary
A deficiency was identified when the facility failed to ensure that the initial care plan and admission assessment for a newly admitted resident were completed by a Registered Nurse (RN), as required by the Delaware Board of Nursing Professional Regulations. Record review showed that both the baseline care plan and the admission assessment, which included documentation of vital signs, skin condition, care needs, and general condition upon arrival, were completed by an LPN. During interviews, the LPN confirmed she performed these tasks, with assistance from an aide for the skin assessment. The Director of Nursing stated that, according to facility policy, LPNs were permitted to complete admission assessments and care plans. These findings were discussed with facility leadership during the exit conference.