Failure to Follow Policies for Documentation, Medication Administration, and Call Light Accessibility
Penalty
Summary
Nurses and nurse aides failed to follow facility policies and procedures in the care of three residents. For one resident with a history of diabetes, atrial fibrillation, anemia, and mobility issues, a change of condition following an unwitnessed fall was not documented in the electronic health record until 36 hours after the incident, despite facility policy requiring documentation as soon as possible after needs are met. The Director of Staff Development confirmed that the resident's needs were addressed immediately after the fall, but the required documentation was delayed. Another resident with hypertension, diabetes, and chronic kidney disease received the antihypertensive medication Hydralazine HCl on three occasions when their systolic blood pressure was below the physician-ordered hold parameter. The Director of Nursing acknowledged that staff did not follow the prescribed blood pressure parameters. Additionally, a resident with legal blindness and muscle weakness was observed with their call light out of reach, contrary to facility policy requiring the call device to be within reach before staff leave the room. These failures were observed through interviews, record reviews, and direct observation.