Failure to Ensure Nursing Staff Competency in Resident Care
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skill sets to provide safe and appropriate care for residents, as evidenced by two specific incidents involving two residents. In the first case, a resident with a history of Parkinson's disease, falls, and other comorbidities experienced an unwitnessed fall and was found on the floor with her right arm under her back. The LPN on duty moved the resident's arm, despite the resident's complaints of severe pain and audible signs of bone injury, such as popping and grinding. The resident repeatedly stated that her arm was broken, and subsequent assessments confirmed a right shoulder fracture. Interviews with other nursing staff indicated that the standard practice should have been to avoid moving a resident with suspected fractures or significant pain until EMS arrived, highlighting a lack of competency in the immediate response to falls and injury assessment by the involved staff member. In the second case, another resident developed a facility-acquired stage 2 pressure ulcer on her sacrum, which progressed to an unstageable ulcer requiring debridement. The prescribed wound care treatment, Santyl ointment, was not available on multiple occasions, and nursing staff substituted Medihoney without obtaining a physician's order for the change in treatment. This substitution was not supported by facility policy or physician direction, and interviews with medical and pharmacy staff confirmed that such changes require a physician's order. The resident's wound continued to decline, with increasing size, depth, and signs of infection, including purulent drainage and odor, ultimately necessitating antibiotic therapy. Additionally, the same resident had a history of swallowing difficulties documented in hospital records prior to admission, but the facility's speech therapy screening did not reflect these concerns. The resident experienced ongoing poor oral intake, mouth pain, and required assistance with eating and hydration. An RN was observed providing fluids via syringe due to the resident's inability to drink from a straw, but there was no documentation of an appropriate assessment or care plan adjustment for her hydration needs. These events collectively demonstrate the facility's failure to ensure that nursing staff had the competencies required to assess, communicate, and provide care in accordance with residents' needs and physician orders.