Failure to Meet Professional Standards in Skin Audits, Medication Administration, and Weight Monitoring
Penalty
Summary
The facility failed to ensure that care and services provided to residents met professional standards of quality in several instances. For one resident with multiple diagnoses including COPD, heart failure, and impaired mobility, the facility's policy required weekly head-to-toe skin audits with documentation of any identified skin conditions. However, a nurse failed to document observed bruising during a body audit and did not perform a complete assessment, as she did not lift the resident's shirt to check for additional injuries. This resulted in undisclosed bruising being identified only after notification from hospital staff, rather than through the facility's own assessment process. Another resident with schizophrenia and morbid obesity was not weighed monthly as required by facility policy and the resident's care plan. The resident's last recorded weight was several months prior, despite interventions in the care plan specifying monthly weights and provider notification for significant changes. The Director of Nursing confirmed that the resident had not been weighed as required. Additionally, a resident with anoxic brain damage and a tracheostomy did not receive medication as ordered by the physician. The physician's order specified that Baclofen should be administered via G-tube, but an LPN crushed the medication and administered it orally. Both the LPN and the unit manager confirmed that the medication was not given by the correct route, and the physician's order had not been updated to reflect any changes following a swallow study. This resulted in the resident not receiving medication as prescribed.