Failure to Ensure Nursing Staff Competency in Resident Assessment and Documentation
Penalty
Summary
Nursing staff failed to demonstrate appropriate competencies and skills in the assessment and documentation of care for two residents. For one resident with a history of cerebral infarction, biliary cirrhosis, heart failure, diabetes, and gout, there was no documented assessment or rationale in the medical record to support the completion of a left foot x-ray. Both the Director of Nursing and the Administrator confirmed that there was no evidence of an assessment or explanation for the x-ray performed. For another resident with diagnoses including Parkinson's Disease, COPD, hypertension, GERD, pain, and edema, nursing staff did not complete or record an assessment when the resident complained of abdominal pain prior to being transferred to a hospital. Interviews revealed that the LPN involved did not recall the resident's code status and believed the decision to transfer was made by hospice staff. Hospital records later showed the resident was diagnosed with a perforated sigmoid colon requiring surgery. The Director of Nursing confirmed there was no documentation to support that a competent assessment was performed by the LPN.