Failure to Ensure RN Oversight in Admission Assessments
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of quality by not having a Registered Nurse (RN) conduct or review admission and readmission assessments for two residents. According to Pennsylvania Code Title 49, RNs are responsible for assessing, planning, implementing, and evaluating nursing care, while Licensed Practical Nurses (LPNs) may participate in these activities using focused assessments. In both cases, the initial admission/readmission assessments, including initial skin assessments, were completed solely by an LPN without evidence of RN oversight or co-signature. Resident 1 was readmitted with multiple diagnoses, including diabetes mellitus, chronic obstructive pulmonary disease, generalized anxiety disorder, suicidal ideation, and a history of venous thrombosis and embolism. Resident 2 was admitted with diagnoses such as cirrhosis of the liver, hepatic encephalopathy, acute posthemorrhagic anemia, acute respiratory failure with hypoxia, and acute kidney failure. The Director of Nursing confirmed that the assessments for both residents were conducted by an LPN without RN involvement, which does not meet the required professional standards.