Admission Audit Documentation

V 2.0

Introduction

Resident Selection

Residents Included

All residents who are first time admissions to the SNF or who are readmissions that were out of the SNF for 24 hours or longer.

• First time admissions OR residents who have been readmitted after more than a month require all the tasks listed below.

• Readmissions who have been readmitted after less than a month AND have the Return from Leave Observation Tool Assessment completed do not necessarily require all the tasks below, depending on the circumstances of the admission. 

  • If the resident still requires the Nursing Admission Evaluation to be completed, then tasks associated with that assessment are still necessary.

  • If not, then all tasks are removed from the audit

• Readmissions who have been readmitted after less than a month who do not have the Return from Leave Observation Tool Assessment Completed are required to complete all the tasks below, or complete the Return from Leave Observation Tool Assessment.

Business Rules

Tasks:

1. Nursing Admission Assessment - Nursing Admission Evaluation completed. (Q26)

   1. Location in PCC:

      1. Assessments → Nursing Admission Evaluation

   2. Business Rule:

      1. IF a resident has been newly admitted,
         THEN there must be a completed Nursing Admission Evaluation following their admission. 

   3. Due Date:

      1. Within 24 Hours of the admission date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the resident has been discharged.

2. Weekly Weights - Weekly weights X 4 weeks scheduled. (Q14)

   1. Location in PCC:

      1. Orders

   2. Business Rule:

      1. IF a resident has been newly admitted,
         THEN there must be an order for Weekly Weights x 4

   3. Due Date:

      1. Within 24 Hours of the admission date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the resident has been discharged.

3. Pneumonia Immunization - Pneumonia Vaccine started and consents obtained (Q38)

   1. Location in PCC:

      1. Immunizations Tab

   2. Business Rule:

      1. IF a resident has been newly admitted,
         THEN there must be a record of a Pneumonia Vaccine administered in the immunizations tab.

      2. IF a resident has been newly admitted,
         AND the resident declines the Pneumonia Vaccine,
         THEN the Nursing staff must address the issue with the resident.

   3. Due Date:

      1. Within 24 Hours of the admission date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the resident has been discharged.

4. Influenza Immunization - Influenza Vaccine started. (Q24)

   1. Location in PCC:

      1. Immunizations Tab

   2. Business Rule:

      1. IF a resident has been newly admitted,
         AND the resident was admitted between the dates of October 1 and March 31,
         THEN there must be a record of an influenza vaccine in the immunizations tab.

      2. IF a resident has been newly admitted,
         AND the resident was admitted between the dates of October 1 and March 31,
         AND the resident declines the Influenza Vaccine,
         THEN the Nursing staff must address the issue with the resident.

   3. Due Date:

      1. Within 24 Hours of the admission date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the resident has been discharged.

5. Catheter Order - Resident has a proper order for a Catheter if indicated by the Nursing Admission Evaluation. (Q42)

   1. Location in PCC:

      1. Assessments → Nursing Admission Evaluation → Section 4

      2. Orders

   2. Business Rule:

      1. IF a resident has been newly admitted,
         AND the Nursing Admission Evaluation, section 4, question 4E.2, indicates the resident requires a catheter,
         THEN there must be an active order for that catheter type.

   3. Due Date:

      1. Within 24 Hours of the assessment date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the resident has been discharged.

6. Activity Preference Assessment - Activity Preference Assessment Completed. (Q31)

   1. Location in PCC:

      1. Assessments → Activity Preferences Interview

   2. Business Rule:

      1. IF a resident has been newly admitted,
         THEN there must be a completed Activity Preference Interview following their admission.

   3. Due Date:

      1. Within 8 Days of the admission date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the resident has been discharged.

7. Diet History Assessment - Diet History/Food Preference Assessment Completed (Q32)

   1. Location in PCC:

      1. Assessments → Diet History/Food Preference

   2. Business Rule:

      1. IF a resident has been newly admitted,
         THEN there must be a completed Diet History/Food Preference Assessment following their admission.

   3. Due Date:

      1. Within 8 Days of the admission date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the resident has been discharged.

8. Social History Assessment - Social History Assessment Completed. (Q33)

   1. Location in PCC:

      1. Assessments → Social History

   2. Business Rule:

      1. IF a resident has been newly admitted,
         THEN there must be a completed Social History Assessment following their admission.

   3. Due Date:

      1. Within 8 Days of the admission date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the resident has been discharged.

9. Bed Safety Assessment - Bed Safety Evaluation Completed. (Q34)

   1. Location in PCC:

      1. Assessments → Bed Safety Evaluation

   2. Business Rule:

      1. IF a resident has been newly admitted,
         THEN there must be a completed Bed Safety Evaluation following their admission.

   3. Due Date:

      1. Within 8 Days of the admission date

   4. Is classified as missed on the report:

      1. N/A

   5. Is no longer relevant to the report:

      1. If the resident has been discharged.