Deficiencies in Resident Care and Protocol Adherence
Penalty
Summary
The facility failed to provide appropriate treatment and care for several residents, as evidenced by multiple deficiencies in adhering to physician orders and facility protocols. For instance, Resident R1 was not weighed as ordered due to the unavailability of a CNA, and Resident R47 also missed a scheduled weight check without a documented reason. These lapses indicate a failure to follow the facility's policy on monitoring residents' nutritional health through regular weight checks. Resident R19, who has diabetes, experienced several instances of elevated blood glucose levels without the physician being notified, as required by the facility's diabetic protocol. Similarly, Resident R62 had low blood sugar readings, but the facility failed to implement the hypoglycemia protocol or notify the physician. These oversights in managing blood glucose levels demonstrate a lack of adherence to established protocols for diabetic care. Additionally, Resident R81, who is NPO and relies on tube feeding, was prescribed medications to be administered orally, contrary to their dietary restrictions. The facility also failed to administer mouthwash as ordered. Resident R90's venous ulcers were not assessed or documented in a timely manner, and several wound care treatments were not completed as ordered. Furthermore, Resident R203 and R253 did not have admission assessments completed, and Resident R253's refusal of medications was not communicated to the physician. These deficiencies highlight significant gaps in the facility's care and documentation processes.
Plan Of Correction
The weight was obtained for R1, R19, and R47. Unable to correct assessments for R90 and R203. The provider was notified of R19's hypoglycemic issue. R62 no longer resides at the facility, unable to correct. R81 no longer resides at the facility, unable to correct. Provider was notified of R253 refusals. Moving forward, clinical morning meetings will include a review of quality of care items and follow-up by DON/designee. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated nursing staff on the weight policy, blood glucose policy, hypoglycemia policy, wound assessment, medication administration, documentation, admission assessment requirements, and notification of physician. To monitor and maintain ongoing compliance, the DON/designee will audit the facility activity report five times weekly for four weeks, then monthly for two months. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.