Failure to Provide Quality of Care in Medication, Skin, Bowel, and Anticoagulation Management
Penalty
Summary
The facility failed to provide quality of care in several areas for five residents, as evidenced by observations, interviews, and record reviews. For one resident with a history of stroke and unable to communicate needs, there was an active order for anticoagulation therapy (coumadin), but no corresponding care plan was in place. Both the LPN/Resident Care Manager and the Director of Nursing Services confirmed that a care plan should have been present but was not. Another resident with multiple diagnoses, including a leg fracture and hypertension, received blood pressure medications (metoprolol tartrate and furosemide) outside of the prescribed blood pressure parameters on multiple occasions, as documented in the medication administration records for August and September. Nursing staff and the Director of Nursing Services acknowledged that medication parameters were not followed as required. Additionally, a resident with chronic constipation and end-stage renal disease experienced multiple episodes of no bowel movements for several consecutive days, with no evidence of laxatives being administered or the facility's bowel protocol being initiated, contrary to facility policy. Two residents with various medical conditions, including arthritis, depression, and malnutrition, had multiple skin injuries such as bruises and skin tears. Documentation of these injuries was incomplete, lacking clear descriptions, sizes, and measurements in the weekly skin checks. Nursing staff and the Director of Nursing Services confirmed that the documentation did not meet expectations, as injuries were not properly described or monitored according to facility procedures.