Deficient Nursing Competency and Medication Management
Penalty
Summary
Nursing staff at the facility failed to demonstrate appropriate competencies and skills necessary to meet the individual care needs of residents. Specifically, a new nurse did not receive effective orientation on the facility's admission process, resulting in failure to obtain and document code status information, secure treatment orders for pressure ulcers, and complete accurate head-to-toe skin assessments. Additionally, a nurse aide did not report observed redness and irritation during catheter care, a nurse administered medications to the wrong resident, another nurse failed to request a prescription when refilling a controlled medication, and a nurse did not utilize available medication resources in the Pyxis system. These deficiencies were identified among five of eight staff reviewed for competency. The report details several resident care issues, including the lack of documentation of advanced directives and code status upon admission, a seven-day delay in treatment for pressure ulcers due to missing treatment orders, and incomplete wound assessments. One resident with a urinary catheter experienced skin breakdown and hygiene issues, with visible redness, irritation, and buildup of a white substance. Medication errors were also noted, including administration of another resident's medications and missed doses due to failure to request prescriptions and use available medication resources. These events were corroborated by record reviews, staff interviews, and observations.