Gordon Lane Care Center
GORDON LANE CARE CENTER in FULLERTON, CA — inspection on June 26, 2024.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident 1's Order Summary Report showed an order dated 5/20/24, to apply a warm compress to Resident 1's right groin area for 20 minutes four times a day for five days.
Review of Resident 1's TAR for May 2024 showed the licensed nurse failed to document her initials on the TAR for the application of Resident 1's warm compress to the right groin area for 20 minutes on 5/21/24 at 0900 and 1300 hours.
On 6/25/24 at 1035 hours, an interview and concurrent medical record review was conducted with LVN 4. LVN 4 verified she was assigned to care for Resident 1 on 5/21/24, duringthe morning shift (0700 to 1500 hours). LVN 4 verified Resident 1's TAR failed to show documentation (licensed nurse's initials) Resident 1's warm compress to the right groin was applied on 5/21/24 at 0900 and 1300 hours. LVN 4 stated the treatment nurse who administered Resident 1's warm compress was responsible for documenting (on the TAR) the warm compress was applied. LVN 4 stated the purpose of documenting the licensed nurse's initials on the resident's TARwas to indicate the resident's treatment was provided as ordered by the physician and applied at the time the treatment was ordered by the physician.
On 6/25/24 at 1145 hours, an interview was conducted with the DON.
The DON was asked about the facility's policy specific to documentation of the resident'streatments.
The DON stated after a licensed nurse administered a treatment, the licensed nurse was required to document on the resident's TAR to show the treatment was administered in accordance with the physician's order.
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