Inaccurate Admission Assessment and Failure to Use Gloves During Peri-Care
Penalty
Summary
The facility failed to ensure professional standards were met when a nurse inaccurately completed admission assessment data for a newly admitted female resident with diagnoses including muscle weakness, musculoskeletal problems, hypertension, and Parkinson’s disease. Review of the resident’s Nursing Admission Assessment dated 1/9/26 showed contradictory fall risk information, documenting that the resident ambulated without problems while also having balance and gait problems when standing or walking. The assessment also incorrectly indicated that the resident did not take an antihypertensive medication, despite a physician’s order for metoprolol tartrate for hypertension, and incorrectly documented that the resident did not have Parkinson’s disease, despite a diagnosis of Parkinson’s and an order for ropinirole. The RN interviewed confirmed these entries were errors and stated they contributed to inaccurate assessment data used to develop the resident’s fall risk care plan. The resident’s Medication Review Report dated 2/17/26 confirmed active physician’s orders for ropinirole for Parkinsonism and metoprolol tartrate for primary hypertension, both ordered on 1/9/26. These orders conflicted with the admission assessment entries that denied the presence of hypertension and Parkinson’s disease and the use of antihypertensive medication. The facility’s Falls and Fall Risk Managing policy, dated 11/17, stated that staff, with input from the attending physician, would identify appropriate interventions related to specific risks and causes to try to prevent residents from falling, indicating that accurate assessment data were required to identify appropriate fall risk interventions. The facility also failed to ensure professional standards were met when a nurse did not use appropriate personal protective equipment while performing peri-care on another female resident. The resident had an order for medicated cream to be applied to the peri-area for MASD, and a progress note documented treatment to the peri-area on 1/19/26 by an LVN. In interviews, a local police officer reported that the LVN admitted he was not using gloves while applying the cream, and the LVN himself stated that after applying the cream to the resident’s vaginal area and between her thighs and vagina, he noticed cream on his bare fingers and acknowledged his finger was exposed. A CNA who was present stated she stood shoulder to shoulder with the LVN and observed him apply the cream over the vaginal area and upper thighs without gloves. The DON stated that nurses should wear gloves for any contact with the vagina and that if a glove breaks, the procedure should be stopped and new gloves applied, and referenced the facility’s Standards for Clinical Practice policy, which requires appropriate PPE (gloves) and protection of privacy, dignity, health, and safety during clinical procedures.
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