Failure to Obtain Orders for Respiratory Equipment and Missed Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure services met professional standards of quality for two residents. For one resident using respiratory medical equipment, the Regional Nurse Consultant (RNC) reported that the resident’s family brought in outside medical equipment that was not ordered by a physician. The RNC stated that staff should be aware of what medical equipment the resident possesses and ensure there are physician orders for those devices, confirming that this was not done. This resulted in the resident using and storing respiratory medical equipment in the facility without corresponding physician orders. For another resident, the facility did not follow the care plan for weekly skin assessments. The resident’s care plan, dated 08/25/25, identified the resident as being at risk for pressure ulcers due to impaired mobility and fragile skin, with an intervention requiring a licensed nurse to assess the resident’s skin at least weekly and report any changes. Review of the electronic health record showed that no weekly skin assessment was documented from 12/22/25 until 01/11/26, a gap of three consecutive weeks. An LPN stated that nurses are supposed to complete head-to-toe assessments every week, and the Wound Care Nurse confirmed that facility nursing staff should have completed weekly skin assessments for this resident but did not. The RNC also confirmed that the weekly skin checks for this resident should not have been missed.
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