Failure to Notify Physician and Document Resident Care
Penalty
Summary
The facility failed to promptly notify the ordering physician and administer medication to a resident with abnormal lab results. Resident #16, who was re-admitted with diagnoses including Type 2 diabetes with complications, experienced a delay in receiving oral medication. The lab results indicating an abnormal culture were reported to the facility, but the medication was not administered until seven days later. The delay was due to a lack of documentation and communication among the nursing staff, as well as the absence of a tracking system for abnormal lab results. Additionally, the facility failed to accurately document and assess the status and condition of a resident with a skin condition. Resident #2, who had a severe cognitive impairment, was observed with exposed and uncovered areas on her left lower extremity. Despite the presence of physician's orders for wound care, there was no documentation of the existence, presence, or condition of the resident's wounds in the nursing progress notes. The lack of documentation and assessment of the resident's skin condition was acknowledged by the Director of Nursing. The deficiencies highlight the facility's failure to adhere to its policies and procedures for communicating urgent lab results and documenting resident care. The absence of a care plan for Resident #16's medication and Resident #2's wound care further contributed to the deficiencies. The Director of Nursing acknowledged the need for prompt notification of physicians and detailed documentation of residents' conditions.
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 indicated treatment. 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 prompt notification of 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.