Failure to Ensure Timely Skin Assessments and Medication Administration
Penalty
Summary
The facility failed to provide necessary care and services related to timely skin assessments and medication administration for several residents. One resident, with a history of diabetes, cerebrovascular disease, chronic kidney disease, hypertension, and blindness in one eye, reported new, painful, and itchy skin lesions to the surveyor. Upon assessment, the LPN stated a dermatology consult would be obtained, but there was no documentation of the new skin issues, no evidence of physician notification, and no new treatment orders in the clinical record. The DON later confirmed that new skin issues should be documented and that an order for cortisone was obtained only after the surveyor's inquiry. Another resident expressed dissatisfaction with care, stating that medications had not been received, showers had been missed for weeks, linens were not changed, and personal preferences for incontinence products were not honored. The DON initially reported that medications had been administered, but the nurse was later observed preparing and administering the resident's medications, which had already been signed off as given in the electronic record. The nurse admitted to pre-pouring medications, signing them off before administration, and delaying medication administration due to taking a lunch break, with morning medications not completed until late morning or noon. A third resident, who had resigned as Resident Council President due to ongoing unresolved issues, reported persistent delays in medication administration, including a specific incident where morning medications were not received until after noon. The resident also noted that afternoon medications were given in the evening. The nurse confirmed that medication passes for the hall were routinely not completed until late morning or noon. The DON acknowledged the resident's complaint but had not initiated a grievance or addressed the ongoing late medication administration concerns. Facility policy requires medications to be administered within one hour of the prescribed time, which was not consistently followed.