Failure to Provide Proper Positioning, Wound Monitoring, and Medication Administration Monitoring
Penalty
Summary
The facility failed to provide routine assistance with proper positioning for a resident who was dining in bed, despite the resident's care plan indicating the need for support due to hemiplegia, GERD, dysphagia, and COPD. Observations showed the resident repeatedly leaning to one side while eating, with staff either not noticing or not providing hands-on assistance unless prompted. The care plan did not include instructions for eating in bed, and facility policy lacked guidance on proper body alignment or support for dining in bed. Staff interviews confirmed that assistance was not consistently offered or provided, and the resident acknowledged improved comfort and ability to eat when repositioned. The facility also failed to consistently assess and monitor a non-pressure wound for another resident. Although the wound was identified and measured at times, there were multiple gaps in documentation and progress notes regarding the wound's status, measurements, and assessments over several months. The care plan did not reflect the presence of the wound, and weekly wound audits were not always accompanied by corresponding progress notes. Staff interviews revealed that daily assessments were not documented in the electronic medical record, and the assistant director of nursing was responsible for weekly measurements, but gaps occurred when the wound was scabbed over without clear documentation of changes. Additionally, the facility did not monitor blood pressure and pulse prior to administering Metoprolol to a resident with physician-ordered parameters. Review of the medication administration record showed no documentation of vital sign monitoring before medication administration over a period of more than two months. Staff interviews confirmed that nurses were unaware of the need to check blood pressure and pulse before giving the medication, despite the order being present in the record. The director of nursing and consultant pharmacist both confirmed that the order required monitoring, but it was not performed or documented.