Failure to Ensure Nursing Staff Competency and Adherence to Physician Orders
Penalty
Summary
Licensed nursing staff failed to demonstrate knowledge and competency in several critical areas of resident care, affecting six out of ten sampled residents. Deficiencies included failure to accurately reconcile medications upon admission, failure to follow up on laboratory orders, administration of medication without a physician's order, failure to report and document gastrostomy tube (G-tube) malfunctions, practicing outside the nursing scope of responsibility, failure to follow physician orders for blood sugar testing, and failure to implement hospice consultation orders. These failures resulted in worsened conditions for residents and created the likelihood of serious injury or death, leading to a determination of Immediate Jeopardy. For one resident with a history of seizures and a G-tube, there were multiple failures in medication reconciliation and laboratory follow-up. Orders for seizure medication levels were entered as completed, but no lab results were found in the medical record. Interviews revealed that nurses lacked access to the lab portal, had not received formal training on the lab process or the admission process, and often relied on informal guidance from coworkers. The DON confirmed that the process for lab follow-up was not followed, and that staff were not supposed to reconcile medications or enter orders without physician communication. Additionally, the emergency drug kit did not contain necessary anti-seizure medications, and some nurses lacked access to the electronic medication dispensing system. In another case, staff failed to report and document a G-tube malfunction for a resident with multiple complex diagnoses. Nurses cut the G-tube without physician orders or documentation, and there was no facility policy on G-tube care. Staff interviews confirmed that cutting the tube was done without proper notification or documentation, and that education on this issue was lacking. In a separate incident, an LPN administered insulin to a resident with diabetes without a physician's order and failed to document blood sugar readings or the amount of insulin given. These actions were only discovered during shift handoff, and the resident required transfer to the emergency room for further care.