Failure to Ensure Competent Nursing Care, Accurate Medication Documentation, and Timely Family Notification
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies and skills in the care of a resident with significant mobility impairments and a history of cerebrovascular accident, resulting in multiple deficiencies. The resident, who was non-ambulatory and dependent on a mechanical lift with two-person assistance for transfers, sustained a severe left femoral fracture after being transferred by a single CNA without the use of the mechanical lift as required by the care plan. Interviews and documentation revealed that the CNA attempted the transfer alone, contrary to facility policy and the resident's care plan, and the incident was initially misrepresented in statements and reenactments. The resident reported that the mechanical lift was not used, and the CNA confirmed during reenactment that she performed the transfer alone. The nurse on duty did not witness the transfer but confirmed the lift was present in the room and that the resident was lifted from the floor without the mechanical lift after the fall. Additionally, there were significant discrepancies in the documentation of controlled medication administration for the same resident. A review of the Medication Administration Record (MAR) and controlled drug inventory sheets for oxycodone revealed multiple instances where doses were recorded on one document but not the other, as well as inconsistencies in administration times. The Director of Nursing confirmed these discrepancies upon review, which were not in accordance with facility policy requiring immediate and accurate documentation of controlled substance administration on both the MAR and inventory sheets. Furthermore, the facility failed to notify the resident's emergency contact or family member following the resident's transfer to an acute care facility after the fall. Documentation in the medical record and transfer forms did not indicate that the family was notified, and interviews with the resident's family confirmed they were not informed by the facility and only learned of the hospitalization through the resident herself. Facility policy required notification and documentation of such changes in condition, which was not followed in this instance.