Failure to Provide Timely Assessment and Documentation After Falls and Skin Issues
Penalty
Summary
The facility failed to ensure that residents received care and services in accordance with professional standards of practice for four residents reviewed for quality of care. In one instance, a resident with dementia, osteoporosis, hypertension, and atrial fibrillation experienced a fall and hit her head. The care plan required immediate assessment, vital signs, and neuro checks, as well as notification of the physician and family. However, the assigned RN did not promptly assess the resident, did not conduct or document a neuro assessment, and failed to notify the physician and family in a timely manner. The incident was not documented in the 24-hour report, and the required incident report was not completed. The RN admitted to not documenting her actions and leaving work without completing the necessary paperwork, and the resident was not sent to the ER until the following day after further assessment by another nurse. Additionally, the facility failed to ensure that head-to-toe skin assessments were completed by a nurse after a CNA identified possible ant bites on three residents. Although the CNA reported the findings to the nurse and ADON, there was no documentation of a nursing assessment or progress note for the affected residents on the dates the bites were identified. Weekly skin assessments were also not documented for these residents during the relevant periods. Interviews with staff confirmed that nurses were responsible for completing these assessments and that there was a lack of accountability and follow-through in ensuring that assessments were performed and documented. Observations and interviews with residents confirmed the presence of ant bites and issues with ants in their rooms. Staff interviews revealed that the facility did not have a dedicated treatment nurse, and that nurses were responsible for weekly and as-needed skin assessments. The ADON and Administrator acknowledged ongoing problems with staff not completing required assessments and documentation, and that there was no system in place to hold staff accountable for these lapses. Facility policy required immediate assessment and documentation after falls and new skin issues, but these protocols were not followed in the cited cases.