Failure to Complete Timely Admission Assessment Upon Resident Re-Admission
Penalty
Summary
A deficiency occurred when nursing staff failed to complete a timely admission assessment for a resident who was re-admitted to the facility following a hospital stay. The resident, who had diagnoses including dementia, bipolar disorder, and schizoaffective disorder, was re-admitted in the afternoon. Despite facility policy requiring a head-to-toe assessment and documentation upon admission or re-admission, the assigned RN did not complete or document the required admission assessment at the time of the resident's return. Interviews revealed that the assigned RN checked on the resident's immediate well-being but did not perform or document a full admission assessment, instead endorsing the task to the treatment nurse and the next shift due to being occupied with another admission. The subsequent RN also did not complete the assessment, believing it was the responsibility of the prior shift, and further endorsed the task to the night nurse. As a result, the clinical admission assessment was not completed until the following early morning, several hours after the resident's re-admission. Facility policy and statements from the Director of Nursing confirmed that the admitting nurse is responsible for assessing and documenting the resident's condition upon arrival, with the option to endorse additional assessments to subsequent shifts. However, in this case, the required admission assessment was neither completed nor documented in a timely manner, contrary to professional standards and facility policy.