Failure to Complete Admission Assessment and Orders for Newly Admitted Resident
Penalty
Summary
Staff failed to complete a nursing admission assessment, wound assessments, and admission orders for two respiratory medications and a urinary catheter for a newly admitted resident. The clinical record for this resident, who had multiple complex diagnoses including COPD, diabetes, atrial fibrillation, end-stage renal disease requiring dialysis, altered mental status, and a history of stroke, lacked documentation of a nursing admission assessment, including vital signs, skin assessment, and catheter assessment. There was no nursing progress note entered until two days after admission, and vital signs were not documented until two days post-admission. Additionally, orders for necessary respiratory medications and catheter care were not entered until several days after admission. A skin and wound assessment was not completed until two days after admission, at which time multiple pressure injuries and arterial ulcers were identified. The resident was subsequently sent to an acute care hospital due to respiratory distress and other symptoms. The Director of Nursing confirmed the absence of documentation regarding the resident's admission in the clinical record. Facility policy requires that information needed for immediate care, including routine care orders, be provided prior to or at the time of admission, but this was not followed in this case.