Failure to Provide Appropriate Care and Documentation for Post-Stroke Resident
Penalty
Summary
Nursing staff failed to provide the standard of quality care to a male resident admitted for rehabilitation following a stroke. The resident, who had dysphagia, expressive aphasia, mild cognitive impairment, and was dependent on staff for all activities of daily living, had a peripheral intravenous (PIV) catheter in place for three days without a physician's order. Documentation showed that the PIV was eventually pulled out by the resident, resulting in bleeding, but there was no evidence of an order for the PIV at any time during his stay. Additionally, staff used the resident's hospital weight as his baseline admission weight instead of obtaining a weight on the facility's scale, as required by facility policy. Subsequent weights showed significant discrepancies, with no repeat weights performed to confirm accuracy and no documentation that nursing staff or the provider were notified of the large weight loss. Furthermore, licensed staff did not document a neurological assessment or monitoring as required after the resident was found unresponsive to verbal stimuli and unable to be awakened. There was no evidence of reassessment or documentation of the resident's neurological status during the shift, despite the facility's stroke program and staff education on the importance of neurological monitoring. These actions and omissions resulted in a failure to provide appropriate treatment and care according to orders, resident preferences, and goals.