Failure to Complete Required Assessments and Medication Self-Administration Reviews
Penalty
Summary
The facility failed to complete required assessments and follow professional standards of practice for three residents. Two residents, both with no cognitive impairment and physician orders for self-administered medications (albuterol inhalers and topical powder), were observed to have these medications at their bedside and reported self-administering them. However, there was no documentation of a medication self-administration assessment or a care plan addressing self-administration for either resident. The DON confirmed that no assessments had been completed and acknowledged that medications should not have been left in the residents' rooms without such assessments, as required by facility policy. Another resident with severe cognitive impairment and a history of falls experienced a witnessed and an unwitnessed fall, the latter resulting in a left hip fracture. After the unwitnessed fall, the resident initially complained of pain, but this was not consistently documented or communicated among staff. Although the physician was notified and indicated that an x-ray should be obtained if needed, this instruction was not documented in the written shift exchange, and subsequent staff were unaware of it. The resident continued to have pain and increased bruising, which was reported to nurses but not fully assessed or documented. An x-ray confirming the fracture was not obtained until several days later, after ongoing pain and functional decline were noted. Facility policy required ongoing assessment and documentation for 72 hours after a fall, including monitoring for changes in pain, mobility, swelling, and bruising. The staff did not consistently follow this policy, as changes in the resident's condition and new bruising were not fully assessed or investigated. The DON and Administrator acknowledged that changes in pain and new bruising should have prompted further assessment and communication with the physician, and that the transition to hospice care should not have altered the standard of care provided.