Failure to Provide and Document Required Care and Assessments
Penalty
Summary
Facility staff failed to provide appropriate care and documentation for multiple residents, resulting in deficiencies related to neurological assessments, skin care, and medication management. In two separate incidents, staff did not properly perform or document neuro checks after residents experienced falls. For one resident, only a single neuro check was documented after a fall, despite the expectation that checks be performed every 15 minutes for the first hour. Another resident also had incomplete neuro check documentation following a fall, with significant gaps between recorded assessments. Additionally, staff failed to obtain current vital signs during a change in condition for one resident, instead relying on outdated information. In another case, a resident on hospice care with orders to have their heels floated while in bed was repeatedly observed with their heels resting directly on the mattress, despite documentation indicating otherwise. Multiple observations confirmed that the intervention was not being implemented as ordered, and nursing staff had signed off on the treatment administration record as if the intervention had been performed. The Director of Nursing confirmed the discrepancy between documentation and actual care provided. A further deficiency involved the management of a resident's low blood pressure. When a blood pressure medication was held due to low readings, staff failed to document the actual blood pressure value, did not record a follow-up measurement, and did not notify the nurse practitioner or physician. The nurse practitioner, who was present in the building, was not informed of the situation until the resident's condition deteriorated significantly, resulting in transfer to the emergency room. The lack of timely communication and documentation was acknowledged by both the nurse practitioner and the Director of Nursing.