Lack of DON Oversight Leading to Communication and Documentation Failures
Penalty
Summary
The facility failed to ensure the nursing department was directed by a qualified full-time Director of Nursing (DON), resulting in a lack of direction and communication within nursing and therapy regarding resident care needs. The Administrator reported the facility had been without a DON for several months, and the Assistant Director of Nursing, an LPN, stated the former DON left approximately eight months prior and the position had not been replaced. The Administrator also stated there were communication issues between departments, that nursing staff did not have access to therapy documentation, and that there was no defined process for communicating therapy recommendations. For one resident with a history of a gastrostomy tube (G-tube), speech therapy documentation over a two‑month period indicated the resident had a feeding tube in place and recommended puree consistencies with therapeutic feedings only with the Speech Language Pathologist (SLP). Nursing progress notes documented that the resident had pulled out the G-tube and that enteral feeding orders were discontinued, with only G-tube site care continued. The SLP later stated that at the time of the resident’s discharge from therapy, the SLP believed the feeding tube remained in place and had not been informed that the resident had pulled out the G-tube and that it was not reinserted. In a separate case, wound documentation for another resident showed an in-house acquired Stage 3 pressure ulcer to the coccyx with tunneling and subsequent bone debridement and treatment, including involvement of a wound doctor and infectious disease due to osteomyelitis and kidney failure considerations. The wound nurse, an LPN, confirmed the pressure ulcer developed at the facility and that the resident was dependent on staff for all care, but was unable to locate the initial assessment from when the pressure ulcer developed, stating she documented the pressure ulcer as developing in July only because that was when she assumed the wound nurse role. These findings demonstrate missing leadership and oversight in the nursing department, as well as gaps in communication and documentation related to resident care and assessments.
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