Failure to Monitor Skin Condition and Administer Medications as Ordered
Penalty
Summary
Facility staff failed to provide appropriate care and services for two residents. For one resident, staff did not assess and monitor a skin rash as required. Although there was a physician's order for topical treatment of acne, the facility's weekly skin observation sheets did not document the presence of acne or a rash over several weeks. An LPN confirmed that abnormal skin conditions should be documented as long as they persist, and acknowledged that the resident was not being properly assessed and monitored when documentation was lacking. Facility policy requires nurses to record changes in a resident's condition, but this was not followed in this case. For another resident, staff failed to administer prescribed medications, including insulin, Coreg, and Midodrine, as ordered by the physician. The resident was alert, oriented, and able to make decisions. On the date in question, the medications were available in the facility's Omnicell system, but were not given. The assistant director of nursing explained that staff are expected to check the Omnicell for medication availability and notify the physician if a medication cannot be administered, but this process was not followed. The failure to administer medications and to notify the physician of their omission was confirmed through record review and staff interview.