Failure to Provide Care According to Professional Standards Results in Resident Harm
Penalty
Summary
The facility failed to provide care according to accepted professional nursing standards for a resident with multiple complex medical needs, including diabetes, dysphagia, and psychiatric concerns. Upon admission, the facility did not develop a baseline care plan for diabetes management, despite the resident's diagnosis and risk for abnormal blood sugar levels. Both the Licensed Nurse and the Director of Nursing confirmed during interviews and record reviews that a baseline care plan for diabetes was missing. Additionally, care plans that were developed contained non-specific interventions, such as monitoring meal intake and offering warm beverages, even though the resident was NPO (nothing by mouth) and receiving nutrition via G-tube. These interventions were not tailored to the resident's actual needs, and staff acknowledged that they should have been updated to reflect the resident's status. There were also failures in medication management and adherence to physician orders. The facility did not clarify conflicting orders regarding the route of medication administration, resulting in medications being given by mouth instead of via feeding tube, contrary to the resident's NPO status and physician orders. Blood pressure monitoring orders related to Seroquel administration were not followed as directed; staff documented identical lying and sitting blood pressures without actually performing the required assessments or notifying the physician of their inability to obtain accurate readings. Furthermore, a PRN Seroquel order was continued for an excessive duration without an end date, and there were conflicting indications for its use in the clinical documentation. The psychiatric assessment and its results were not incorporated into the care plan, and staff were unclear about who was responsible for reviewing and communicating consultant notes to the physician. The report also identified that Licensed Vocational Nurses (LVNs) were performing tasks outside their scope of practice, such as developing and revising care plans, which is the responsibility of Registered Nurses (RNs) and physicians. Multiple care plans for the resident were initiated and revised by LVNs, contrary to regulatory requirements. As a result of these failures, the resident experienced abnormally high blood sugar, required transfer to an acute care hospital, and ultimately died.