Deficiencies in Medication Administration, Skin Care, and Nutritional Support
Penalty
Summary
The facility failed to provide adequate and appropriate health care to its residents, as evidenced by several deficiencies. One significant issue involved a resident who did not receive timely notification and administration of medication following abnormal lab results. The resident's lab results were reported to the facility, but there was a delay of approximately one week before the medication was administered. The facility's process for handling abnormal lab results was not followed, as there was no documentation of the physician being notified promptly, and the medication order was not entered into the system in a timely manner. Another deficiency was observed in the care of a resident with a skin condition. The facility failed to accurately document and assess the status and condition of the resident's skin. Observations revealed exposed and uncovered areas on the resident's skin, but there was no mention of these in the nursing progress notes. The facility's documentation did not reflect the current status or condition of the resident's skin, and there was no specific care plan in place for the resident's surgical site. Additionally, the facility did not ensure proper nutritional assessments and interventions for a resident, resulting in significant weight loss. The resident experienced a severe weight loss over several months, and the facility's documentation and monitoring of the resident's nutritional intake were inadequate. The resident's daughter expressed concern about the weight loss and the lack of communication regarding her mother's dietary preferences and needs. The facility's failure to follow physician's orders for nutritional support further contributed to the resident's decline in health.
Plan Of Correction
Resident #16 received ordered completed on with no adverse effects. Resident #2 surgical site was dressed and documented on with suture removal. Audit of residents with surgical sites for documentation and care plan development and implementation. Audit of residents with current orders for completion of physician notification and prompt start of if indicated. 100% Inservice for all licensed nurses on results with prompt physician notification and prompt start of ordered treatment. 100% Inservice for all licensed nurses for documentation of surgical sites and care plan development and implementation for surgical sites. DON or designee to audit weekly for results to physician with prompt start of ordered treatment and surgical site documentation with care plan development and implementation. DON or designee to report findings of all audits to QAPI committee meeting monthly. Resident #37 care plan updated for maintenance and prevention. 100% audit of residents with, for development and implementation of care plans as identified. 100% Inservice of all licensed nursing staff for care plan development and implementation for. DON or designee to audit residents with for care plan development and implementation weekly for 30 days and monthly ongoing. DON or designee to report findings of care plan audits to QAPI committee meeting monthly. Resident #51 was sent to hospital on as of. Resident #51 remains in hospital. Resident #167 and #169 orders for feeding were clarified and corrected on. 100% audit of all feeding residents for orders to meet nutritional needs, one order and RD documentation. Inservice DON and Registered Dietician of documentation and feeding order requirements. DON or designee to audit for feeding orders and RD documentation with feeds weekly times 4 weeks and then monthly ongoing. DON or designee to report findings of audits to QAPI committee meeting monthly.