F0684

G

Failure to Provide Licensed Nursing Assessment and Oversight for Wounds, Change in Condition, and PICC Line Care

Port Angeles, Washington Survey Completed on 01-21-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents received necessary nursing assessment, monitoring, and care, including wound management and change-in-condition evaluation, and the improper use of unlicensed staff for tasks requiring nursing judgment. For one resident with bilateral lower extremity venous and/or arterial ulcers, medication technicians documented daily edema monitoring on multiple days, even though the Director of Nursing Services (DNS) later stated that assessing and monitoring edema and performing wound care were outside their scope of practice. The resident’s care plan did not include documentation of edema, wound problems, wound interventions, signs and symptoms of infection, or which staff were responsible for wound care management. A nursing progress note later documented multiple blisters, open wounds, and drainage on both lower extremities, but wound cultures were not ordered until the resident was seen by an outside wound care team several days later.

Orders for advanced wound care, including cleansing and application of sterile dressings such as calcium alginate with silver and collagen to multiple areas of both lower legs, were initiated, yet a medication technician signed off as having performed this wound care on several mornings. During this period, a provider note documented that the resident was somnolent and mumbling incoherently, with a meal tray in front of them that they were not eating, and speculated that over-sedation from oxycodone might be the cause. The medication administration record showed the resident received two doses of oxycodone that day, and the higher-dose order was discontinued that afternoon. The electronic health record contained no nursing notes for a ten-day period leading up to the resident’s transfer to the hospital. A certified nursing aide reported being concerned about the resident’s lack of responsiveness on the night shift and stated they notified the nurse twice, but the nurse only checked the resident’s pulse and did not call EMS. The resident was later found unresponsive, hypothermic, and was sent to the hospital, where emergency room documentation showed very low body temperature, infected lower extremity wounds with multiple organisms, bloodstream infection, severe thrombocytopenia, and a physician-documented diagnosis of severe sepsis with organ dysfunction and possible disseminated intravascular coagulation; the resident subsequently died at the hospital.

For a second resident admitted with severe esophageal stenosis and on a full liquid diet, the care plan allowed thin liquids, and a daily skilled evaluation documented normal respiratory status and clear lung sounds on one date, but no nursing evaluations were completed for the following two days. A provider note documented that the resident was short of breath, had audible wheezing, and a non-productive cough, and a chest x-ray was ordered but never completed. A nursing note entered by a nurse technician later documented that the resident was struggling to breathe, had audible wheezing, and was coughing up blood, and that EMS was called and the resident was admitted to the hospital for aspiration pneumonia. The nurse technician later stated the resident had been coughing up blood for two days, did not know if an RN had assessed the resident during that time, and confirmed that no RN assessed the resident before EMS was called, citing that there was only one RN in the building for 83 residents and that they felt overwhelmed. The DNS stated that, given the resident’s symptoms, the chest x-ray should have been obtained as soon as possible, that the resident should have been placed on alert and closely monitored by a licensed nurse, and that it was outside the nurse technician’s scope of practice to make the judgment call to send a resident to the emergency room.

For a third resident admitted for IV antibiotic therapy for pneumonia with a PICC line in the right arm, a provider note documented the resident’s concern that the PICC dressing was falling off and at risk for infection, and indicated that nursing would be notified so the dressing could be changed. The treatment administration record showed two orders for PICC dressing changes: one weekly order, which was completed on one date, and a second order to change the dressing as needed every 24 hours. There was no documentation that the dressing was changed on the date the concern was raised. Both orders required measurement of upper arm circumference and external catheter length on admission and with each dressing change, but there was no documentation of these measurements. The resident’s care plan acknowledged the presence of the PICC but did not include interventions, monitoring parameters, directions for blood draws, instructions to avoid blood pressures on the PICC arm, or instructions on the sterile technique required for dressing changes. The DNS stated that the PICC dressing should have been changed as ordered and that detailed instructions and interventions should have been added to the care plan.