Deficiencies in Staff Competency and Orthostatic Hypotension Procedures
Penalty
Summary
The facility failed to complete initial and annual skills competencies for four Restorative Nursing Aides (RNAs), which are crucial for maintaining residents' mobility and preventing contractures. During interviews and record reviews, it was revealed that the Director of Staff Development (DSD) acknowledged the absence of these competencies in the employee files of the RNAs. The DSD emphasized the importance of these competencies in ensuring that RNA staff are up-to-date with their skills and can perform their tasks correctly. The Director of Rehabilitation confirmed that no initial or annual skills competencies were completed for the RNA staff, and the Director of Nursing (DON) reiterated the necessity of these competencies for the proper execution of the RNA program. The facility also failed to ensure that a Licensed Vocational Nurse (LVN) understood the purpose and procedure for checking orthostatic hypotension. During interviews, the LVN admitted to not knowing how to take orthostatic blood pressures and not seeking guidance. The DON explained that accurate orthostatic blood pressure readings are essential for managing medication and treatment plans. The facility's policy on measuring blood pressure indicated specific criteria for identifying orthostatic hypotension, which the LVN did not follow. Another LVN also demonstrated a lack of understanding regarding the procedure for obtaining orthostatic blood pressure readings. The LVN incorrectly described the process and purpose of these readings, which was confirmed by the DSD as inaccurate. The facility's policy outlined the correct method for measuring orthostatic hypotension, which involves noting changes in blood pressure from sitting to standing positions. The LVN's failure to follow this procedure resulted in inaccurate documentation of blood pressure readings, as evidenced by identical readings recorded on multiple occasions.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/11/25, the Director of Rehabilitation (DOR) conducted annual competencies for the facility's Restorative Nursing Assistants (RNAs). On 3/10/25, License Vocational Nurse (LVN) 4 and LVN 2 received one-on-one in-servicing with return demonstration by the Director of Staff Development to ensure they understood the definition of orthostatic hypotension and how to perform orthostatic hypotension monitoring. How the facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/17/25, the Director of Staff Development (DSD) conducted an audit on the facility's Restorative Nursing Assistant (RNA) employee files to ensure all Restorative Nursing Assistants had competencies completed. No other residents were affected by this deficient practice. On 3/19/25, the Medical Record Director conducted an audit on residents receiving orthostatic hypotension monitoring to ensure orthostatic hypotension monitoring was being recorded accurately. There was 1 other resident affected by this deficient practice. The resident affected by this deficient practice experienced no negative outcome. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/11/25, the Director of Nursing and Director of Staff Development in-serviced the DOR, Physical Therapist, Occupational Therapist, and Speech Therapist on the facility's policy and procedure titled, "Restorative Nursing Program Guidelines," with emphasis on nursing aides being trained in the techniques that promote resident involvement in the activity. The in-service included completing initial and annual competencies and any training needed when areas of improvement are identified. The Administrator will conduct audits on new hires, RNAs, and current employees who receive new certifications for Restorative Nursing Assistant employee files, to ensure employees have initial competencies as needed. The DSD will conduct audits to ensure RNAs receive their annual competencies when due. On 3/19/25, the Director of Nursing and Director of Staff Development in-serviced Nursing Staff including, but not limited to LVNs and Registered Nurses, on the facility's policy and procedure titled, "Blood Pressure, Measuring," with emphasis on orthostatic hypotension being defined as a 20 millimeters of mercury (mmHg) decline in systolic blood pressure (the contraction phase of the heart) or a 10 mmHg decline in diastolic blood pressure (relaxing phase of the heart) upon standing and to measure orthostatic hypotension, noting the changes in both the systolic and diastolic blood pressure in the standing position compared to the sitting position. The Medical Records Director will conduct an audit on orthostatic hypotension monitoring daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' orthostatic hypotension monitoring is being recorded accurately. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Staff Development will report to the Quality Assessment and Assurance committee during its monthly meeting the status of the compliance for RNAs' initial and annual competencies being completed, for three months or until compliance is met. The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting the status of the compliance for orthostatic hypotension monitoring being monitored accurately, for three months or until compliance is met. The Medical Records Director will conduct an audit on orthostatic hypotension monitoring daily for five days, weekly for two weeks, and monthly thereafter to ensure residents' orthostatic hypotension monitoring is being recorded accurately.