Failure to Demonstrate Competency in Resident Care and Assessment
Penalty
Summary
Facility staff failed to demonstrate appropriate competencies and skills sets in the care of two residents. In the first instance, a resident with a gastrostomy tube and multiple diagnoses, including anoxic brain injury and failure to thrive, was observed with a tube feeding machine alarming due to a flow error. A CNA entered the room, performed hand hygiene, donned gloves, and attempted to restart the machine without notifying a nurse. The CNA stated that CNAs are not trained to troubleshoot gastrostomy tubes, and the DON confirmed that CNAs should not restart the machine but should alert a nurse instead. In the second instance, a resident with chronic respiratory failure, anoxic brain injury, and metabolic encephalopathy experienced tachycardia and low oxygen saturation. The assigned RN completed an SBAR form and contacted the provider, who instructed to transfer the resident to the hospital. However, the nurse failed to gather and document all relevant and pertinent information, such as current blood pressure, respirations, and temperature, at the time of the change in condition, as required by facility protocol. The DON confirmed that a complete assessment should have been performed and documented.