Failure to Meet Professional Standards in Care, Documentation, and Medication Management
Penalty
Summary
Facility staff failed to ensure that services provided met professional standards of quality for multiple residents. For one resident with a PICC line, staff did not perform required dressing changes or flushes after the completion of IV antibiotics, and there was no documentation of these actions or provider orders for them. The dressing was observed to be compromised and the date illegible, with the resident unable to recall when it was last changed. The facility's own policy required dressing changes every seven days and immediate changes if the dressing integrity was compromised, but these standards were not met. Another resident with an order for TED hose/compression stockings did not have the stockings available for approximately two weeks, yet staff continued to document their application and removal as if the care was provided. The resident confirmed not having the stockings during this period, and the facility's documentation policy required factual and accurate records, which was not followed in this case. Additional deficiencies included failure to obtain and document laboratory tests as ordered for a resident on anticoagulant therapy, improper documentation and clarification of medication orders for a resident who was NPO but had oral medications documented as given, and failure to clarify and address duplicate medication orders for another resident, resulting in inaccurate medication administration records. These actions and inactions were identified through resident and staff interviews, clinical record reviews, and facility policy reviews.