Failure to Implement Consultant Recommendations for Resident Care
Penalty
Summary
The facility failed to ensure the highest practical care for a resident, identified as Resident 93, by not implementing consultant recommendations. Resident 93, who had a history of pain and stiffness in his right hand, was observed on January 21, 2025, complaining of a 'cold hand' with no grasp and partially contracted fingers. He mentioned that he sits on his hand to warm it and straighten his fingers. A review of his clinical record showed that he had seen a plastic surgeon on January 13, 2025, who noted improvement in his range of motion with some exercise. The physician recommended warm soaks twice a day and resuming hand therapy. However, there was no documentation that the facility implemented these recommendations. The Director of Nursing confirmed these findings during an interview on January 24, 2025, acknowledging that the recommendations were only implemented after the surveyor's inquiry.
Plan Of Correction
Cited: Resident 93 has orders regarding soaking hands and orders reflecting therapy to assist with hand therapy. • Like: The facility will do a two-week look back to ensure residents who attend appointments and return with follow up recommendations, that recommendations are timely addressed. • Education: DON/designee will educate nursing staff on ensuring appointment follow up recommendations are addressed timely. • Audits: DON/designee will audit 5 residents weekly x 4 weeks and monthly x2 months to ensure recommendations from resident appointments are followed up timely. Results will be taken through QAPI.