Failure to Ensure Staff Competency and Adherence to Physician Orders During Resident Change of Condition
Penalty
Summary
Nursing staff failed to demonstrate appropriate competency in the care of a resident with type 2 diabetes and hypertension, resulting in a series of missed interventions during a significant change in the resident's condition. The resident experienced nausea, vomiting, and a critically high blood sugar reading of 382 mg/dl. Despite physician orders to notify the physician if blood sugar exceeded 350 mg/dl, the LVN on duty did not contact the physician, did not recheck the resident's blood sugar, and did not obtain or document vital signs during this episode. The LVN also provided a trash can instead of a clean basin for vomiting, contrary to infection control policy, and administered scheduled medication early at the resident's request without physician notification. Record reviews and staff interviews confirmed that the LVN was aware of the physician's orders and facility policies but failed to follow them, including not recognizing the need for immediate physician intervention for hyperglycemia and associated symptoms. The LVN admitted to not notifying the physician, not rechecking blood sugar, and not taking vital signs, and stated that these actions should have been performed. Other nursing staff and supervisors corroborated that these omissions were not in line with facility policy and could have warranted further medical intervention. Additionally, the facility failed to ensure annual competency assessments and performance evaluations for several staff members, including CNAs, LVNs, and RNs. Employee files lacked documentation of required annual competency checks and performance reviews, and facility leadership acknowledged uncertainty regarding the frequency of these assessments. Facility policies referenced the need for competency validation and performance evaluation but did not specify required intervals, and the facility assessment tool and employee handbook did not provide clear guidance on this matter.