Failure to Adhere to Professional Standards in Medication, Dental, and Clinical Follow-Up Documentation
Penalty
Summary
The facility failed to ensure that care and services were provided in accordance with professional standards of quality for three of five sampled residents. For one resident with a history of hypertension and shoulder pain, a lidocaine 4% patch was applied without dating, timing, or initialing the patch at the time of administration. The nurse was unable to confirm when the previous patch was removed, and there was no documentation of patch removal in the Medication Administration Record (MAR). The nurse also stated that patches were never dated or initialed, and there was no clear method to determine when patches were removed, contrary to facility expectations and medication guidelines. Another resident, who had moderate cognitive impairment and was missing upper front teeth, reported that a dental mold for new partial upper dentures had been completed months prior, but no follow-up had occurred. The Social Service Director (SSD) did not have a system in place to monitor or track follow-up dental appointments and was unfamiliar with the dental notes indicating the need for follow-up. The SSD acknowledged not maintaining a list of residents requiring follow-up visits and not documenting updates or referrals in the resident's chart, despite being responsible for coordinating resident care. Additionally, the facility failed to maintain a running total of daily fluid intake for another resident, and a potassium lab result for a different resident was not communicated to the prescriber, with no evidence of clinical follow-up or intervention. These failures were identified through observation, interview, and record review, and were directly related to lapses in documentation, communication, and adherence to professional standards of care.