Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to provide the highest practicable care and adhere to professional standards of practice for wound care and medication administration. Specifically, the facility did not implement wound care treatments as ordered for a resident with a lateral right ankle vascular ulcer. The treatment, which included cleansing and applying specific wound dressings, was signed off as completed on the dayshift but was actually performed on the evening shift, indicating a delay in care. Additionally, the facility did not adhere to scheduled medication administration times for 21 out of 23 residents reviewed. Medications were administered several hours later than scheduled, with delays ranging from 1 1/2 to 9 hours. This widespread issue affected numerous residents, each with varying numbers of medications scheduled for administration at specific times. The Nurse Practitioner was informed of the late medication administrations two days after the incident, and it was noted that no adverse reactions occurred among the residents. During an interview, the Director of Nursing and the Nursing Home Administrator acknowledged that treatments and medications should be administered as ordered and not signed off until completed. The nurse responsible for the residents was terminated following the incident.
Plan Of Correction
Resident 9 wound care provided, and residents 1, 2, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 22 and 23 were assessed and no adverse reactions, therefore no further adjustments to treatment was required per CRNP. Nurse involved has since been terminated. A comprehensive review of current Residents medication administration and treatment for the previous 1 weeks will be audited to ensure that medications and treatments were completed as ordered. Director of nursing / Designee will educate licensed staff on F tag 0684 quality of care, focusing on medication administration and wound treatments. Audits of 5 random residents will be completed by unit managers / designee per week for 4 weeks to ensure medications are administered timely and wound treatments are completed. Results of the audits will be reviewed by the QAPI committee for recommendations.