Failure to Provide Person-Centered Care and Monitoring for Skin Conditions and Low Blood Pressure
Penalty
Summary
The facility failed to provide care and services in accordance with residents' goals and professional standards of practice in several areas, including the management of non-pressure skin conditions and monitoring of low blood pressure. For multiple residents, staff did not follow physician orders or facility policy regarding wound care, skin assessments, and documentation. One resident was found with a bandage on their elbow that had not been changed for nine days after the treatment order was discontinued, and staff failed to document weekly skin assessments as required. Another resident on anticoagulant therapy exhibited multiple bruises, but staff did not document or report these as adverse reactions, nor did they clarify or follow orders for skin checks and provider notification. A resident with a surgical wound did not have weekly skin assessments or wound measurements documented for nearly four weeks, despite orders and care plan directives. Another resident, who was on hospice and at risk for pressure ulcers, had a bandage on their forehead, but staff did not include this resident in weekly wound rounds or document required skin assessments, wound measurements, or refusals. The documentation in the treatment administration record was unclear, and staff could not provide evidence that assessments were completed as expected. Additionally, the facility failed to monitor and notify the provider regarding low blood pressure readings for a resident with a history of low BP and a pacemaker. The care plan lacked clear parameters for when to notify the provider, and staff did not document interventions or notifications for multiple low BP readings. Interviews with staff revealed a lack of understanding about when to notify the provider and an absence of instructions in the care plan or medication administration record. No documentation was provided to show that the provider was informed or that interventions were implemented in response to low BP readings.