Failure to Ensure Nursing Staff Competency in Therapy Referral Process
Penalty
Summary
Nursing staff failed to ensure proper competency in completing therapy referrals for a resident with multiple medical conditions, including moderate dementia, diabetes with neuropathy, and failure to thrive. The resident was observed having difficulty drinking without spilling and not feeding himself, with records indicating decreased food and fluid intake and concerns about pocketing medication. Nursing staff initiated a referral to therapy for evaluation of eating and swallowing issues, but the process was not completed correctly. The nurse who initiated the referral completed both the nursing and therapy sections of the electronic referral form and locked it, preventing the therapy department from being notified or able to respond. As a result, the therapy department did not receive or act on the referral, and the resident was not evaluated for the identified swallowing and eating concerns. The facility did not have a policy for nursing competencies, and the nurse involved was new to the facility.