Failure to Notify MD and Monitor Wound Care
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for two residents. Resident 71, diagnosed with peripheral vascular disease and hypertension, had a physician's order to notify the Medical Director if blood glucose levels were outside the specified parameters. However, on multiple occasions, Resident 71's blood sugar levels exceeded the upper limit of 250, yet there was no documentation or evidence that the Medical Director was notified as required. This lack of communication was confirmed during an interview with the Director of Nursing, who acknowledged that the Medical Director should have been informed. Resident 88, diagnosed with chronic obstructive pulmonary disease and heart failure, had an in-house acquired moisture-associated skin damage (MASD) identified on December 9, 2024. Despite the presence of this condition, there was no further documentation or assessment of the wound to monitor its progress. The Director of Nursing indicated that weekly wound and skin evaluations should have been conducted to track the MASD, but this was not done, leading to a deficiency in the care provided to Resident 88.
Plan Of Correction
1. Resident 71 has been discharged from the facility. Wound assessment has been completed for resident 88. 2. A comprehensive review of current residents with orders to call MD for blood glucose level outside of the parameters will be completed to ensure that there is documentation that the provider was notified if BS is outside of the parameters within the last 30 days. A comprehensive review of current residents with identified MASD will be conducted to ensure that there are weekly skin evaluations completed for the last 30 days. 3. The facility will take further steps to validate the problem does not re-occur by in-servicing the Licensed Nurses on Ftag 684 with a focus on physician notifications and weekly wound evaluations. 4. Compliance will be monitored by the Director of Nursing/Designee using the Blood Glucose Audit and Wound Audit through an audit of five residents weekly x 3 weeks and monthly x 2 per each individual concern. Findings will be reported to the QAA Committee to determine the need for further audits.