Failure to Use RNs for Required Admission, Discharge Teaching, and Post-Fall Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services were provided in accordance with Delaware State Board of Nursing scope of practice requirements and professional standards. For one resident admitted on 11/22/25, an LPN completed the Nursing Admission/Readmission/Annual/Significant Change Assessment, as well as the lift/transfer/reposition evaluation, AIMS assessment, PHQ-9 evaluation, and bedrail evaluation in the EMR, despite state regulations specifying that admission assessments must be completed by an RN. For another resident admitted on 6/27/25 with diagnoses including breast cancer and dementia, an LPN completed the Nursing Admission/Readmission/Annual/Significant Change Assessment and documented completion of the admission nursing assessment, with no evidence in the EMR that an RN performed the required admission assessment. The deficiency also includes failures related to discharge education and post-fall assessment. One resident admitted on 11/11/25 and discharged on 11/19/25 had a discharge plan documented entirely by a social work assistant and a nursing clerical assistant, with no evidence that any licensed nursing personnel reviewed the discharge plan documentation. EMR progress notes for this resident contained no evidence that an RN provided discharge education prior to discharge; instead, a social worker documented that the resident chose to discharge and was educated on the risks of not completing rehab. For the resident with breast cancer and dementia who experienced a fall on 7/8/25, a fall incident report and neurological evaluation flow sheet showed that an LPN completed the initial post-fall neurological assessment and documentation, even though state regulations require an RN to complete the initial post-fall assessment. Review of the EMR confirmed there was no RN post-fall assessment documented for this resident.
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