Failure to Complete Timely RN Assessments After Change in Condition and Hospital Return
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely RN assessments in response to a significant change in condition and upon readmission from the hospital for one resident. The resident had a history of stroke, thyroid disorder, hypertension, and cardiovascular disease related to bradycardia and hyponatremia, and required assistance with ADLs and transfers. On 12/30/2024, LPN staff documented that the resident became increasingly agitated and combative, attempting to climb out of a window, hitting, scratching, and yelling at staff, and being considered a danger to self. An APRN was notified, a one-time antianxiety medication was ordered and attempted but spit out by the resident, and the APRN then ordered a transfer to the hospital. EMS records showed the resident was transported that evening. Despite this documented significant change in mental and behavioral status and transfer to the hospital, record review did not identify that an RN assessment was completed at the time of the change in condition. After evaluation and treatment at the hospital, including psychiatric assessment and medication changes, the resident returned to the facility on 1/1/2025. A nursing note by an LPN documented the resident’s return, and the hospital discharge summary included recommendations for medication adjustments and geriatric psychiatric follow-up. However, review of the 24-hour report sheets and the resident’s medical record revealed no RN assessment documented upon the resident’s return from the hospital. Interviews with the RN supervisor who worked on the date of the initial change in condition confirmed she could not recall assessing the resident and stated that if she had done so, it would have been documented. She also acknowledged that an RN assessment should be completed for a significant change in condition and upon admission/readmission. The DON similarly stated she would expect an RN assessment in these circumstances. Facility policies on Change in Resident Condition and Nursing Documentation required an RN assessment when there is a significant change in physical, mental, or emotional status and that documentation occur as soon as possible after the assessment, but no such RN assessments were found for either the change in condition or the readmission.
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