Deficiencies in Nursing Competency and Medication Administration
Penalty
Summary
The facility failed to ensure that both licensed nurses and CNAs possessed and demonstrated the required competencies and skill sets necessary to provide safe and effective nursing care, specifically in the area of skin assessment. One resident was admitted with a surgical incision that required monitoring and care, as indicated in the transfer orders and admission skin assessment. Despite the presence of a visible surgical wound, the facility staff did not assess, monitor, or provide care for the wound from the date of admission until several months later, when the issue was identified by an outside dialysis clinic. Multiple staff members, including licensed nurses and CNAs, provided care to the resident during this period but failed to perform the required skin assessments or document the condition of the wound. Interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that the facility's competency checklists for both CNAs and licensed nurses did not include skin assessment, even though it was a required competency. Both the DSD and DON acknowledged that the omission of skin assessment from the competency evaluations contributed to the failure of multiple staff members to assess and document the resident's surgical wound as required. The lack of proper assessment and documentation persisted until the wound was finally evaluated and the sutures were removed months after admission. Additionally, the facility failed to follow physician's orders regarding medication administration for another resident. Specifically, the facility did not administer lidocaine patches as prescribed for pain management. Review of facility policies and procedures confirmed that medications are to be administered only upon clear, complete, and signed orders from authorized prescribers, and in accordance with written orders. However, the facility did not comply with these requirements, resulting in the resident not receiving the ordered medication.
Plan Of Correction
F0726 - Competent Nursing Staff Immediate Corrective Action: On 09/02/2025, a treatment care plan was developed for Resident #10 Surgical site. All Licensed Competency Skill Checks were initiated immediately. Residents Affected: On 09/02/2025, the RN Supervisor reviewed all residents with pressure injuries and surgical sites to ensure that care plans were developed, reviewed, updated, and revised. No other residents were affected. Corrective Action: Licensed nurses were in-serviced by the DON, beginning on September 3rd, 2025, on the process for developing, reviewing, and updating care plans for surgical sites, and skills competency. Monitoring of Corrective Action: The DON or their designee will review care plans for all new and all wounds in the weekly wound meeting the same week to verify compliance and continue with skill competency every month. If deficiencies are identified, the DON or their designee will immediately revise the care plan. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025 --- P0755 - Pharmacy Services/Procedures/Pharmacist/Records Immediate Corrective Action: On 09/03/25 - In accordance with the facility's general documentation guidelines, Lidocaine patch administration was recorded on the MAR for Resident #11. All medication errors for the residents identified in the citation were immediately corrected, the physician was notified, and residents were assessed for adverse outcomes. On 09/03/2025 - In accordance with the facility's general documentation guidelines, a count sheet was created to ensure all Lidocaine patches are administered. Residents Affected: On 09/04/2025, the RN Supervisor and designee reviewed the MAR and ensured all Lidocaine patches were administered. No residents were identified as being affected at this time. Corrective Action: All licensed nursing staff were re-educated/inservice on safe medication administration practices, including the "5 Rights" (right resident, right drug, right dose, right route, and right time). Monitoring of Corrective Action: The DON or their designee will perform weekly med pass observations for 12 weeks, focusing on safe practices and documentation accuracy, and review medication disposition record logs to verify compliance. Visual checks will be conducted to ensure patches have been applied to the residents. The results of these audits will be presented to the QAPI Committee on a quarterly basis for further monitoring and/or action planning as needed. Completion Date: 10/25/2025