Failure to Follow Professional Standards in Assessment, Documentation, and Medication Administration
Penalty
Summary
Facility staff failed to follow professional standards of practice in several instances involving three residents. In one case, a resident with severe cognitive impairment experienced a fall resulting in a right hip fracture. The resident was found on the bathroom floor and was unable to bear weight on her right leg. Despite this, the resident was moved to a wheelchair and monitored at the nurses' station before being sent to the emergency room. Documentation did not show that a proper assessment was performed prior to moving the resident, nor was there evidence of how long the resident remained in the wheelchair before transfer. The facility's own falls management policy and staff interviews confirmed that a post-fall assessment should have been conducted before moving the resident, but this was not documented or performed. In another instance, staff failed to follow professional standards regarding the pronouncement of death for a resident with moderate cognitive impairment. The clinical record included a progress note from an LPN stating the resident had no signs of life and that the DON was notified and pronounced the resident dead. However, there was no documentation of a registered nurse's assessment at the time of death, and a late entry was made by the RN much later. Additionally, the facility could not provide a policy guiding the pronouncement of death, and the LPN's assessment and findings leading to the call to the DON were not documented in the clinical record. A third deficiency involved a resident with multiple chronic conditions, including CHF and COPD, for whom staff documented daily weights and medication administration that did not occur. The electronic medication administration record (eMAR) was initialed as if daily weights were obtained, but there was no area to document the actual weights until a later date, and the weight record showed weights were not taken daily as ordered. Staff also initialed the administration of an inhaler medication that was not available in the facility, as confirmed by progress notes and the DON. Facility policies required documentation of all services provided and that medication administration be documented immediately after administration, but these standards were not followed.