F0658

E

Failure to Ensure RN Assessments for Residents Transferred to Hospital

Fairview, Pennsylvania Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that nursing services met professional standards of quality by not having a Registered Nurse (RN) conduct required assessments for residents who experienced falls, changes in condition, or device dislodgement that led to hospital transfers. Pennsylvania Code Title 49, Chapter 21, specifies that RNs are responsible for assessing human responses, planning, implementing, and evaluating nursing care, and collecting complete and ongoing data to determine nursing care needs. The facility’s own job descriptions state that LPNs administer resident care under RN and/or physician supervision and are to observe, evaluate, and report abnormal findings, while RNs are to observe, assess, and report abnormal findings and significant changes in condition.

For seven sampled residents (R10–R16), the clinical records showed events requiring emergency transfer to the hospital, but lacked evidence of RN assessments prior to transfer. One resident with arthropathy, sacroiliitis, Type 2 diabetes, and stroke fell from bed, sustained injury, and was sent to the hospital. Another resident with irregular heartbeat, depression, heart disease, and fibromyalgia fell in the hallway, sustained injury, and was transferred for emergency evaluation. A resident with kidney stones, a displaced kidney drainage tube, UTI, and heart failure required emergency transfer when the kidney drainage tube became displaced. Additional residents with diagnoses including bacterial infection in the blood, heart failure, Type 2 diabetes, irregular heartbeat, high blood pressure, emphysema, COPD, stroke, heart attack, fainting, and heart disease experienced changes in condition that resulted in emergency hospital transfers.

Interviews with LPN staff (E1–E5) confirmed that they were expected to complete their own assessments on newly admitted residents, residents with injuries, and residents with changes in condition, and that they were responsible for obtaining provider orders for emergency transfers based on their assessments. These LPNs also reported that there were many times when no RN was available to complete such assessments. Review of the clinical records for the seven residents confirmed the absence of RN assessments before hospital transfer. In an interview, the DON acknowledged that the assessments for these residents were conducted by LPNs without RN oversight or assistance and stated unawareness that an RN was required to perform assessments for residents experiencing a change in condition. The cited regulations included 28 Pa. Code 201.14(a), 201.18(b)(1)(3), 201.18(e)(1), 211.10(d), and 211.12(d)(1)(5).