Failure to Follow Professional Standards in Post-Fall Assessment, Insulin Administration, and Pressure Mattress Settings
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for three residents. In the first instance, a resident with dementia and high blood pressure experienced a fall, but there was no documentation that a set of vital signs was obtained at the time of the initial assessment or prior to physician notification. The only vital signs recorded were from before the fall, and the first post-fall vital signs were not documented until several hours later. The DON confirmed that the expectation is for vital signs to be taken immediately after a fall, but this was not done or documented in this case. In the second instance, insulin administration practices did not adhere to standards of care regarding site rotation. Two residents received insulin injections in the same location repeatedly, as documented in the MAR, and staff interviews confirmed that there was no standard practice for rotating injection sites. This was contrary to established guidelines, which recommend systematic rotation within an area to prevent complications. The Nursing Home Administrator acknowledged the lack of adherence to a standard of care for insulin administration and site rotation. The third deficiency involved the use of a pressure-reducing mattress for a resident with a history of significant weight loss. The mattress was set for a weight range much higher than the resident's current weight, as confirmed by both observation and staff interviews. The settings were only adjusted after surveyor intervention, despite the care plan specifying that mattress settings should be based on the resident's weight and checked for proper functioning.