Failure to Complete Required RN Assessments After Resident Incidents
Penalty
Summary
The facility failed to ensure that Registered Nurse (RN) assessments were completed following significant events for two residents. In the first case, a resident with dementia, fibromyalgia, and anxiety, who was at risk for skin breakdown, was found to have a new open area on the coccyx by an LPN. The LPN documented cleansing and dressing the wound and noted that the nursing supervisor was notified to obtain a treatment order. However, there was no subsequent RN assessment documented in the electronic medical record, as required by facility policy. The RN supervisor on duty did not recall being informed of the new pressure ulcer, and there was no evidence of an accident and injury report being completed for this event. In the second case, a resident with a history of femur fracture, autistic disorder, and seizures, who required assistance with mobility and transfers, was found on the floor by a family member. The LPN on duty, along with three other staff, assisted the resident off the floor and back into bed. The LPN did not inform the RN supervisor of the fall, citing the end of her shift and inability to locate the RN. As a result, the required RN assessment after the fall was not completed, and the resident was not assessed by an RN until the following day by an APRN. Facility policy required an RN assessment after any fall or significant change in condition, which was not followed in this instance. Both incidents demonstrate a failure to adhere to facility policies that mandate RN assessments following significant changes in resident condition, such as new pressure ulcers or falls. The lack of timely RN assessments and documentation after these events constituted deficiencies in meeting professional standards of quality care for the residents involved.