Failure to Complete Comprehensive Readmission Assessment
Penalty
Summary
The facility failed to ensure a comprehensive and accurate assessment was completed for one resident upon readmission from an acute care hospital stay. Review of the electronic health record showed that no complete head-to-toe assessment was performed when Resident #1 returned from the hospital on the specified date. During an interview, the DON confirmed that Resident #1 was not assessed upon arrival from the hospital, acknowledging that facility practice requires all residents returning from the hospital to receive an assessment, including a head-to-toe skin assessment, upon arrival/admission. This failure to perform the required assessment upon readmission meant that the resident’s condition, including skin status, was not comprehensively evaluated as per facility expectations, and the report notes that this deficient practice is likely to not accurately calculate the resident’s risk score for skin breakdown or falls.
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