Failure to Meet Professional Standards in Skin, Constipation, and Fall Management
Penalty
Summary
The facility failed to ensure that nursing services consistently met professional standards of practice for multiple residents, particularly in the areas of skin condition management, constipation, and fall prevention. For several residents with non-pressure skin conditions, such as abrasions and skin tears, staff did not consistently assess, monitor, or implement physician or wound consultant orders. For example, one resident with a history of skin abrasions and tears had no documented care or monitoring for a significant skin tear that required hospital treatment, and another resident with extremely dry skin and a history of psoriasis did not have interventions or treatments documented or implemented despite visible symptoms and resident complaints. In another case, a resident who sustained a skin tear after a fall did not have the wound monitored or treated for over a week, despite increasing pain and signs of possible infection. The facility also failed to follow established protocols for the assessment and management of constipation. Multiple residents with a history or risk of constipation, some of whom were on medications known to cause constipation, went several days without a bowel movement without staff implementing standing orders or as-needed medications as directed by care plans and physician orders. Documentation showed that staff did not consistently track bowel movements, administer prescribed interventions, or notify providers when residents experienced extended periods without a bowel movement. Residents reported not being asked about their bowel movements and not receiving interventions unless specifically requested. Additionally, the facility did not consistently implement or document fall prevention and post-fall monitoring protocols. Residents identified as high risk for falls experienced multiple unwitnessed falls, with incomplete or missing documentation of neurological checks and vital sign monitoring as required by facility policy. In several instances, there was no evidence that new interventions were implemented after repeated falls, and progress notes lacked follow-up on potential latent injuries. Staff interviews confirmed that required monitoring and documentation were not consistently performed after falls, and that these omissions could jeopardize resident health and safety.