Failure to Document and Administer Care as Ordered
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards for three residents. Resident 9, who had a tracheostomy and was dependent on a ventilator, had an order for triple antibiotic ointment to be applied to moisture-associated skin damage at the tracheostomy site every shift. However, there was no clinical documentation of any skin damage or assessments from September 24, 2024, to January 8, 2025. The Director of Nursing (DON) confirmed the absence of documentation and noted that the physician assessed the site on January 8, 2025, finding no skin damage and discontinued the ointment. Resident 14, diagnosed with COPD and hypertension, had multiple treatment orders for pressure areas and wounds on the left buttock and thigh. The treatment administration records (TAR) for October, November, and December 2024 showed several instances where treatments were not documented as completed. The DON believed the treatments were completed but acknowledged the lack of documentation, which should have been recorded on the TAR. Resident 17, with Type 2 Diabetes Mellitus and end-stage renal disease, had orders for blood sugar checks and medication administration. The medication administration records for October, November, and December 2024, and January 2025, revealed multiple instances where blood sugar checks were not documented, and a high blood sugar reading was not followed up with physician notification. Additionally, Midodrine was administered despite a blood pressure reading that should have prompted holding the medication. The DON confirmed these discrepancies and expected staff to document medication administration and follow-up communication with the physician as ordered.
Plan Of Correction
Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding. One: actions taken for situation identified: 1) The Facility recognizes that it cannot retroactively correct the situation for resident R9, R14, R17. 2) The Facility reviewed R9, and had a new skin assessment completed, site has been healed and treatment d/cd. R14 was assessed and is still receiving treatment to her open areas. R17 chart was reviewed for missing documentation and medication administration. 3) All current residents were reviewed for vital signs, incomplete documentation and correct skin assessments and orders relating to those skin assessments. Two: system changes and measures that will be taken: 1) All Licensed staff will be in-serviced on documentation accuracy, including vital signs, notifying physician on follow up and on lab values and abnormal lab values, accurate skin assessments and treatment orders. 2) Documentation will be monitored at Daily Clinical meetings and staff will be notified as necessary for corrections. Three: monitoring mechanism to assure compliance: 1) The Director of Nursing or her designee will conduct audits on five (5) random residents 3x a week for 4 weeks for compliance with documentation accuracy, including vital signs, notifying physician on follow up and on lab values and abnormal lab values, accurate skin assessments and treatment orders, and careplans, then five (5) random residents 1 x a week for 2 months. 2) The Director of Nursing will report findings at Continuous Quality Improvement Committee meetings.