Failure to Complete Accurate Assessments and Provide Timely Interventions for Residents with Edema and Skin Conditions
Penalty
Summary
Staff failed to appropriately complete resident assessments and provide timely interventions for two residents with significant medical needs. For one resident with a history of coronary artery disease, hypertension, heart failure, localized edema, and acute respiratory failure, the care plan did not document the use of compression hose as ordered. Despite a physician's order discontinuing the use of compression hose, staff continued to apply them, and there was confusion among staff regarding whether the resident should be wearing them. Documentation in the electronic health record and medication administration record was inconsistent, with staff unsure about current orders and responsibilities for monitoring and documenting the use of compression hose. For another resident with multiple cardiac diagnoses and long-term use of anti-coagulant therapy, the initial assessment failed to document the presence of purpura or chronic bruising on the forearms and hands. The care plan instructed staff to monitor for bruising due to anti-coagulant use, but there was no ongoing documentation of bruising in the medication administration record or nursing progress notes after the initial mention. Staff interviews revealed a lack of clarity regarding who was responsible for tracking and documenting the bruising, and the initial assessment's omission led to the absence of a tracking task for this condition. Both deficiencies were identified through clinical record review, observations, resident and staff interviews, and policy review. The findings indicate that the facility did not ensure accurate and complete assessments or timely interventions according to physician orders and resident needs, resulting in lapses in care planning, documentation, and monitoring for residents with complex medical conditions.