Failure to Ensure Nursing Staff Competency and Adherence to Care Protocols
Penalty
Summary
Licensed nursing staff failed to demonstrate knowledge and competency in providing care and services to several residents, resulting in multiple deficiencies. In one case, a resident with severe cognitive impairment and multiple comorbidities, including dementia and being under hospice care, experienced an unwitnessed fall. The fall was not immediately reported or documented by the nurse, and the physician was not notified. The resident was found on the floor by a CNA, who notified the nurse, but the nurse assumed it was a behavioral issue and did not follow facility policy for unwitnessed falls. The resident subsequently developed pain, and an X-ray two days later revealed an acute right hip fracture. Pain medication was not administered until after the fracture was confirmed, despite a standing order for PRN morphine. The incident was only brought to the attention of the DON and hospice nurse after a family member reported the resident's pain. In another instance, staff failed to follow physician orders for laboratory testing. A resident with a history of depression and dementia was prescribed Depakote, with an order for periodic Depakote level monitoring. The required lab work was not completed as ordered, and there was no documentation of the lab being performed or of the provider being notified about the missed lab. Staff interviews revealed confusion about the process for lab orders, with discrepancies between what was documented and what was actually completed. The DON confirmed there was no facility policy related to following physician orders for lab work. Additional deficiencies included failure to provide a safe, hazard-free environment and failure to verify resident identification prior to medication administration. A disposable razor was found in the bathroom of a resident with severe cognitive impairment, contrary to staff statements that razors should be kept by staff and only used under supervision. During a medication pass, a nurse administered medications to a resident without verifying their identification, in violation of facility policy. These failures were confirmed through staff interviews and record reviews.