Failure to Follow Self-Administration Determination and Complete Wound/Catheter Treatments and Documentation
Penalty
Summary
The deficiency involves the facility’s failure to follow professional standards of quality in medication/treatment administration and documentation for two residents. For Resident 1, the Self-Administration of Drugs Assessment, completed by the IDT, indicated it was not safe for the resident to self-administer drugs. Despite this, Treatment Nurse 1 reported that the resident was performing his own suprapubic catheter flushes, and she documented the ordered daily flushes as completed on the Treatment Administration Record (TAR) even though she did not perform them and had never observed the resident doing them. The TAR for Resident 1 also showed blank entries, without any notation of refusal or other explanation, for ordered treatments including suprapubic catheter care and left ischium wound care on multiple dates. Resident 1’s clinical information showed he had neuromuscular dysfunction of the bladder, HTN, atrial fibrillation, an indwelling suprapubic catheter, and required moderate to maximal assistance with ADLs, while his MDS indicated intact cognitive skills for daily decisions. He reported that on one day he did not receive any of his daily skin treatments because there was no treatment nurse available, and he stated that his suprapubic catheter required daily care. Treatment Nurse 1 acknowledged that on one of the cited dates she did not provide any skin treatment because the resident refused suprapubic catheter care, yet this refusal and the missed treatments were not documented on the TAR. She further acknowledged that she signed for treatments as if she had administered them on multiple dates when she had not. For Resident 2, who had diagnoses including neuromuscular dysfunction of the bladder, HTN, and atrial fibrillation, and required moderate to maximal assistance with ADLs, the physician’s orders included daily sacrococcyx wound care with NS, medihoney, and dry dressing, and daily topical ketoconazole cream to the right lower back. Review of Resident 2’s TAR showed multiple blank entries for these ordered treatments on several dates, with no documentation of completion, refusal, or any reason for the omissions. Registered Nurse 1 confirmed that a blank TAR entry with no notation means the treatment was not done and that the correct process is to document why a treatment was not completed rather than leaving the TAR blank. Facility policies on self-administration of medications and prevention of pressure ulcers/skin care required IDT determination of self-administration safety and detailed documentation of skin care, refusals, and resident condition, which were not followed in these cases.
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