Failure to Provide Timely and Appropriate Care per Orders and Resident Needs
Penalty
Summary
Staff failed to perform weekly skin assessments as ordered for a resident with a history of stroke, spinal cord dysfunction, and hemiplegia. The resident's care plan and physician's order required weekly skin checks and completion of a skin evaluation form, but documentation showed that these assessments were missed on two occasions. One LPN signed off on a skin check without actually performing or documenting the assessment, citing being interrupted and not returning to complete the task. The Director of Nursing confirmed that this was a breakdown in communication and that documentation of unperformed tasks was unacceptable. A resident with severe cognitive impairment and abnormal posture was not positioned according to the prescribed wheelchair positioning plan. The plan required the use of a pelvic positioning belt and specific use of leg rests to maintain proper body alignment and safety. Observations revealed the resident self-propelling in the wheelchair without the belt fastened and with leg rests in place when they should have been removed. The assigned nursing assistant did not follow the care card instructions, stating she believed the belt would be a restriction, and failed to apply it as required by the care plan and physician's order. Another resident with osteoporosis and a recent fracture experienced a change in skin condition, including redness and inflammation in the buttocks and genital region, which was not reported to licensed nursing staff as required. The nursing assistant who observed the skin issue did not escalate the finding, despite being aware of the policy to report such changes. Additionally, two residents did not receive timely incontinent care, with one resident left in a saturated brief for over three hours and not repositioned during that time. The assigned nursing assistant admitted to not providing care every 2-3 hours as required, citing oversight, even though staffing levels were normal.