Failure to Complete Wound Treatment and Seizure Assessment
Penalty
Summary
The facility failed to complete a wound treatment as ordered for one resident and failed to complete an assessment for another resident. For the first resident, who had diagnoses including type 1 diabetes and pressure ulcers, staff did not perform a prescribed wound treatment to the left ischium in a timely manner after the dressing was removed following a bowel movement. The resident reported the dressing was removed around 4:30 AM, but the wound treatment was not completed until 9:30 AM. Interviews revealed that the assigned RN did not complete the treatment due to not feeling well and was unable to stand long enough to perform the procedure. The DON was informed of the situation and instructed the RN to review the physician orders and complete the treatment, but the RN deferred the task to the next shift. For the second resident, who had Alzheimer's disease, a seizure disorder, and was dependent on staff for all activities of daily living, staff failed to complete and document an assessment after seizure-like activity was reported by CNAs. The RN on duty was notified of pre-seizure behavior but only performed a brief visual check, did not administer medication due to its expiration, and did not return to reassess the resident, citing personal health issues. Progress notes lacked documentation of an assessment related to the reported seizure activity, contrary to facility policy requiring assessment and documentation when seizure activity occurs.