Failure to Complete Timely RN Assessments After Incidents and Care Omissions
Penalty
Summary
The facility failed to ensure that Registered Nurse (RN) assessments were completed in a timely manner for multiple residents following incidents involving accidents, resident-to-resident altercations, and potential abuse. In one case, a resident with hemiplegia and other significant medical conditions was found with discoloration around the left eye. Although an LPN assessed the injury and notified the APRN, there was no documentation of an RN assessment or investigation into the cause of the injury, despite facility policy requiring such action for injuries of unknown origin. The Director of Nursing Services (DNS) confirmed that the RN supervisor was responsible for the assessment and documentation, but no explanation was provided for the omission. In another incident, two residents were involved in a physical altercation, with one resident punching another in the face. The event was witnessed and reported to an LPN, who performed an assessment and notified the APRN and responsible party, but did not notify the nursing supervisor. There was no evidence of an RN assessment for either resident following the altercation, contrary to facility policy that requires immediate notification of the nursing supervisor and a thorough assessment after any allegation or observation of abuse. The DNS acknowledged that the nursing supervisor should have been informed and an assessment completed. Additionally, four residents with significant cognitive and physical impairments did not receive timely incontinent care, with gaps ranging from nearly 10 to over 10 hours between care episodes. When this lapse was identified, there was no documentation of RN assessments or skin checks for these residents, despite facility procedures directing a physical assessment in such situations. Late entries by LPNs and an APRN note did not address the period during which care was omitted. The DNS confirmed that RN assessments were not completed as required after the incident was discovered.