Failure to Assess and Document Care for Newly Admitted Hospice Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide care and treatment to a newly admitted resident in accordance with professional standards of practice, including assessment, basic care tasks, and pain management. The resident was admitted for end-of-life care with multiple diagnoses and arrived at the facility appearing restless, under distress, non-verbal, and repeatedly attempting to get out of bed. A collateral contact reported that the resident had been calm and able to go out in a wheelchair while in the hospital, but shortly after admission to the facility the resident was groaning, restless, and appeared significantly different. Staff C, an RN, stated the resident was very restless on admission, that they were concerned about falls and placed a mattress on the floor next to the bed, and had a CNA sit with the resident. Staff D, a CNA, recalled the resident as very restless, confused, not making eye contact, repeatedly removing their hospital gown, and trying to get up, with staff trading off to sit with the resident to prevent self-injury. Staff F, an RN manager on duty, reported working remotely to enter medications into the medical record and being informed that the resident was very agitated and crawling out of bed, and then learning that the hospice nurse had arrived and the resident was sent back to the hospital. Record review showed the resident was in the facility for approximately 2.5 hours, and the electronic chart contained only a single nursing note and a later social services note about a declined bed hold. The nursing note documented the resident’s arrival time, restlessness, distress, attempts to get off the stretcher and out of bed, assignment of a CNA to sit with the resident, and that the hospice nurse contacted the hospice physician, who ordered the resident sent to the hospital. There was no documentation of vital signs, weight, admission nursing assessment, skin assessment, pain assessment, baseline care plan, consent for positioning the bed against the wall, or documentation of 1:1 monitoring or the specific care provided and the resident’s response. Staff C acknowledged that no assessment or vital signs were obtained due to the resident’s restlessness, and Staff E confirmed there were no additional documents beyond what was in the electronic record. The DON confirmed that the absence of these assessments and documentation did not meet the facility’s expectations for care of newly admitted residents.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.