Failure to Follow Professional Standards in Medication Administration and Wound Assessment
Penalty
Summary
Facility staff failed to adhere to professional standards of nursing practice in several instances involving three residents. For one resident with multiple insulin orders, staff did not administer insulin and other medications within the required one-hour window of the scheduled time on numerous occasions. This included delays of up to several hours for both scheduled and sliding scale insulin doses, as well as a weekly injectable medication. The resident expressed concern about the timing of her insulin administration, noting that doses were sometimes given so late that subsequent doses had to be skipped or were administered too close together. The Director of Nursing confirmed that medications are expected to be given within an hour of the scheduled time, and facility documentation corroborated the repeated delays. In another case, a nurse provided a resident with medication and left the room without ensuring the medication was ingested. The incident was discovered when the resident’s family found medications left on the bed. The nurse involved acknowledged walking away while the resident was taking the medication and was subsequently reprimanded. There was no documentation in the clinical record or progress notes regarding this incident, and the unit manager confirmed the event had occurred and that staff are not permitted to leave medications with residents unsupervised. For a third resident, staff failed to document a thorough assessment of a pressure ulcer upon admission and during the first week of the resident’s stay. The initial nursing assessment noted the presence of a stage 2 pressure ulcer but did not include any description of the wound’s size, appearance, or characteristics. Daily treatment was provided and documented, but no descriptive assessments were recorded until a week later when a wound nurse practitioner performed a detailed evaluation. Both the unit manager and the DON acknowledged that nurses are expected to document wound appearance and characteristics, and facility policy requires such documentation for residents with wounds.